Visit numbers and corresponding visit rates from 2001 to 2004 were adjusted by 0.92 to account for non–nursing home, institutionalized patients (see the eMethods in the Supplement).
eMethods. Nursing home patient classification.
Brownell J, Wang J, Smith A, Stephens C, Hsia RY. Trends in Emergency Department Visits for Ambulatory Care Sensitive Conditions by Elderly Nursing Home Residents, 2001 to 2010. JAMA Intern Med. 2014;174(1):156-158. doi:10.1001/jamainternmed.2013.11821
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Despite having 24-hour access to health care professionals, nursing home residents have disproportionately high rates of emergency department (ED) visits, a large portion of which are potentially preventable.1,2 These acute care visits, often classified as potentially preventable using ambulatory care sensitive conditions (ACSCs), can be harmful to residents’ functional outcomes relative to treatment in their familiar setting.3 Given the increase in reporting and enforcement of the Centers for Medicare & Medicaid Services’ regulations about nursing home quality, we hypothesized that the rate of ED visits for ACSCs by elderly nursing home patients had declined during the last decade.
This study was exempt from review by the University of California, San Francisco Committee on Human Research. We conducted a retrospective analysis of ED visits by elderly nursing home residents using data from the 2001 to 2010 National Hospital Ambulatory Medical Care Survey. We excluded patients who were younger than 65 years (85.3%), had died in the ED (0.5%), or did not reside in a nursing home (88.8%) (see the eMethods in the Supplement).
We used the Agency for Healthcare Research and Quality’s Prevention Quality Indicators to identify visits for ACSCs based on International Classification of Diseases, Ninth Revision diagnosis codes. To calculate rates of ED use per nursing home resident, we used resident-year denominators from the Centers for Medicare & Medicaid Services’ Online Survey Certification and Reporting data.
Significance of the trends in rates of ED visits for ACSCs and other diagnoses by nursing home patients was assessed using Poisson regression. We further analyzed the distribution of visits for ACSCs by diagnosis and assessed the significance of changes in that distribution using χ2 test across 5 two-year blocks to preserve significant sample sizes.
All analyses were performed using commercially available software. SAS, version 9.2 (SAS Institute Inc) and SUDAAN, version 10.0 (RTI International) were used.
Between 2001 and 2010, the number of ED visits by elderly nursing home patients increased 12.8%, from 1.9 to 2.1 million. Nineteen percent were for ACSCs. The rate of ED visits for ACSCs increased from 263 to 320 visits per 1000 residents (21.8%), but the change was not statistically significant (P = .93) (Figure). The increase in the rate of ED use for non-ACSCs, from 1186 to 1461 visits per 1000 residents (23.2%), was also nonsignificant (P = .94). The rate of ED visits for ACSCs relative to visits for other diagnoses remained constant, fluctuating around 0.22.
Pneumonia was the most common ACSC in the sample, accounting for 27.9% of all ED visits for ACSCs (Table). Urinary tract infections rose from 23.4% of all visits for ACSCs in 2001-2002 to 33.4% in 2009-2010, although the change in the distribution of diagnoses was not significant (P = .17).
Despite increasing legislation to monitor and enforce nursing home standards and quality of care, no decrease has occurred in the rate of ED visits for ACSCs during the last decade. The absolute rate of ED visits for ACSCs among elderly nursing home residents (273 visits per 1000 in 2007) was substantially higher than past estimates of ED visit rates for ACSCs in the general adult population (31.9 visits per 1000 in 2007).4 Similarly, their overall ED visit rate (1310 visits per 1000 in 2007) was almost 3 times higher than past estimates of ED use by all Americans older than 65 years (476.8 visits per 1000 in 2007).4
High ED visit rates among elderly nursing home residents are in some ways expected, for ACSCs and overall, given the prevalence of serious illness and disability in this population.5 Furthermore, the uncoordinated payment systems of Medicare and Medicaid, for which most elderly nursing home patients are dual eligible, can incentivize these transfers.5 Evidence6 has shown that reducing these potentially preventable visits has the potential to generate significant savings for public insurance programs.
Corresponding Author: Julia Brownell, BA, Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, Room 1E2, San Francisco, CA 94110 (firstname.lastname@example.org).
Published Online: October 28, 2013. doi:10.1001/jamainternmed.2013.11821.
Author Contributions: Dr. Hsia had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Brownell, Wang, Hsia.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: Brownell, Wang.
Critical revision of the manuscript for important intellectual content: All authors.
Obtained funding: Hsia.
Administrative, technical, and material support: Brownell.
Study supervision: Smith, Stephens, Hsia.
Conflict of Interest Disclosures: None reported.
Funding/Support: This project was supported by University of California, San Francisco Clinical and Translational Science Institute grant KL2 TR000143 from the National Center for Advancing Translational Sciences, National Institutes of Health (Dr Hsia) and by the Robert Wood Johnson Foundation Physician Faculty Scholars Program (Dr Hsia).
Role of the Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: Amy Markowitz, JD, provided insightful comments on the manuscript.