Emergency department utilisation by older people in metropolitan Melbourne, 2008–12: findings from the Reducing Older Patient’s Avoidable Presentations for Emergency Care Treatment (REDIRECT) study
Danielle Mazza A F , Christopher Pearce A B , Angela Joe A , Lyle R. Turner A , Bianca Brijnath A , Colette Browning C , Marianne Shearer D and Judy Lowthian C EA Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia. Email: chris.pearce@monash.edu; ajoe.melb@gmail.com; lyle.turner@monash.edu; bianca.brijanth@monash.edu
B Melbourne east General Practice Network (trading as Outcome Health), 1/5 Lakeside Drive, Burwood East, Vic. 3151, Australia.
C Royal District Nursing Service Institute, 31 Alma Road, St Kilda, Vic. 3182, Australia. Email: colette.browning@monash.edu
D Gippsland Primary Health Network, 16 Kirk Street, Moe, Vic. 3825, Australia. Email: marianne.shearer@gphn.org.au
E Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia. Email: judy.lowthian@monash.edu
F Corresponding author. Email: danielle.mazza@monash.edu
Australian Health Review 42(2) 181-188 https://doi.org/10.1071/AH16191
Submitted: 30 August 2016 Accepted: 26 December 2016 Published: 20 February 2017
Journal compilation © AHHA 2018 Open Access CC BY-NC-ND
Abstract
Objective Older patients are over-represented in emergency departments (ED), with many presenting for conditions that could potentially be managed in general practice. The aims of the present study were to examine the characteristics of ED presentations by older patients and to identify patient factors contributing to potentially avoidable general practitioner (PAGP)-type presentations.
Methods A retrospective analysis was performed of routinely collected data comprising ED presentations by patients aged ≥70 years at public hospitals across metropolitan Melbourne from January 2008 to December 2012. Presentations were classified according to the National Healthcare Agreement definition for PAGP-type presentations. Presentations were characterised according to patient demographic and clinical factors and were compared across PAGP-type and non-PAGP-type groups.
Results There were 744 519 presentations to the ED by older people, of which 103 471 (13.9%) were classified as PAGP-type presentations. The volume of such presentations declined over the study period from 20 893 (14.9%) in 2008 to 20 346 (12.8%) in 2012. External injuries were the most common diagnoses (13 761; 13.3%) associated with PAGP-type presentations. Sixty-one per cent of PAGP-type presentations did not involve either an investigation or a procedure. Patients were referred back to a medical officer (including a general practitioner (GP)) in 58.7% of cases.
Conclusion Older people made a significant number of PAGP-type presentations to the ED during the period 2008–12. A low rate of referral back to the primary care setting implies a potential lost opportunity to redirect older patients from ED services back to their GPs for ongoing care.
What is known about the topic? Older patients are increasingly attending EDs, with a proportion attending for problems that could potentially be managed in the general practice setting (termed PAGP-type presentations).
What does this paper add? This study found that PAGP-type presentations, although declining, remain an important component of ED demand. Patients presented for a wide array of conditions and during periods that may indicate difficulty accessing a GP.
What are the implications for practitioners? Strategies to redirect PAGP-type presentations to the GP setting are required at both the primary and acute care levels. These include increasing out-of-hours GP services, better triaging and appointment management in GP clinics and improved communication between ED clinicians and patients’ GPs. Although some strategies have been implemented, further examination is required to assess their ongoing effectiveness.
References
[1] Di Somma S, Paladino L, Vaughan L, Lalle I, Magrini L, Magnanti M. Overcrowding in emergency department: an international issue. Intern Emerg Med 2015; 10 171–5.| Overcrowding in emergency department: an international issue.Crossref | GoogleScholarGoogle Scholar |
[2] Elder E, Johnston AN, Crilly J. Review article: systematic review of three key strategies designed to improve patient flow through the emergency department. Emerg Med Australas 2015; 27 394–404.
| Review article: systematic review of three key strategies designed to improve patient flow through the emergency department.Crossref | GoogleScholarGoogle Scholar |
[3] Kirby SE, Dennis SM, Jayasinghe UW, Harris MF. Frequent emergency attenders: is there a better way? Aust Health Rev 2011; 35 462–7.
[4] Lowthian J, Curtis A, Stoelwinder J, McNeil J, Cameron P. Emergency demand and repeat attendances by older patients. Intern Med J 2013; 43 554–60.
| Emergency demand and repeat attendances by older patients.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC3s3lsl2gtQ%3D%3D&md5=97270ed5caa701cf19034589484344a5CAS |
[5] Lowthian JA, Smith C, Stoelwinder JU, Smit DV, McNeil JJ, Cameron PA. Why older patients of lower clinical urgency choose to attend the emergency department. Intern Med J 2013; 43 59–65.
| Why older patients of lower clinical urgency choose to attend the emergency department.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC38nnsVWrsA%3D%3D&md5=2eb44f2ee3fb4c8eaf649594d4e236fdCAS |
[6] National Health Performance Authority (NHPA). Healthy communities: use of emergency department and GP services in 2013–14. Sydney: NHPA; 2016.
[7] Canadian Institute for Health Information (CIHI). Source of potentially avoidable emergency department visits. Ottawa: CIHI; 2014.
[8] Lowthian JA, Jolley DJ, Curtis AJ, Currell A, Cameron PA, Stoelwinder JU, McNeill JJ. The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995–2015. Med J Aust 2011; 194 574–8.
[9] Faulkner D, Law J. The ‘unnecessary’ use of emergency departments by older people: findings from hospital data, hospital staff and older people. Aust Health Rev 2015; 39 544–51.
| The ‘unnecessary’ use of emergency departments by older people: findings from hospital data, hospital staff and older people.Crossref | GoogleScholarGoogle Scholar |
[10] Lowthian JA, Curtis AJ, Cameron PA, Stoelwinder JU, Cooke MW, McNeil JJ. Systematic review of trends in emergency department attendances: an Australian perspective. Emerg Med J 2011; 28 373–7.
| Systematic review of trends in emergency department attendances: an Australian perspective.Crossref | GoogleScholarGoogle Scholar |
[11] Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 2002; 39 238–47.
| Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions.Crossref | GoogleScholarGoogle Scholar |
[12] Mazza D, Pearce C, Lowthian J, Browning C, Shearer M, Joe A, Turner LR, Biezen R, Brijnath B. REDIRECT: Reducing older patients’ avoidable presentations for emergency care treatment. Melbourne: The Department of General Practice, Monash University; 2015.
[13] Victorian State Government Department of Health and Human Services Australia. Victorian emergency minimum dataset – VEMD. Victorian hospital data reports reference files. Melbourne: Victorian Government Health Information; 2014.
[14] Australian Bureau of Statistics. Population by age and sex, regions of Australia – Victoria by geographical classification [ASGS 2011]. Canberra: Commonwealth of Australia; 2013.
[15] Australian Bureau of Statistics (ABS). An introduction to socio-economic indexes for areas (SEIFA). Catalogue no. 2039.0. Canberra: ABS; 2006.
[16] Australian Institute of Health and Welfare (AIHW). Australian hospital statistics 2012–13: emergency department care. Health Services Series no. 52. Catalogue no. HSE 142. Canberra: AIHW; 2014.
[17] Freed G, Gafforini S, Carson N. Age-related variation in primary care-type presentations to emergency departments. Aust Fam Physycian 2015; 44 584–8.
[18] Nagree Y, Camarda VJ, Fatovich DM, Cameron PA, Dey I, Gosbell AD, McCarthy SM, Mountain D. Quantifying the proportion of general practice and low-acuity patients in the emergency department. Med J Aust 2013; 198 612–15.
| Quantifying the proportion of general practice and low-acuity patients in the emergency department.Crossref | GoogleScholarGoogle Scholar |
[19] Allen P, Cheek C, Foster S, Ruigrok M, Wilson D, Shires L. Low acuity and general practice-type presentations to emergency departments: a rural perspective. Emerg Med Australas 2015; 27 113–18.
| Low acuity and general practice-type presentations to emergency departments: a rural perspective.Crossref | GoogleScholarGoogle Scholar |
[20] Burkett E, Martin-Khan MG, Scott J, Samanta M, Gray LC. Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change. Aust Health Rev 2016;
| Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change.Crossref | GoogleScholarGoogle Scholar |
[21] Buckley DJ, Curtis PW, McGirr JG. The effect of a general practice after-hours clinic on emergency department presentations: a regression time series analysis. Med J Aust 2010; 192 448–51.
[22] Joe A, Lowthian J, Shearer M, Turner L, Brijnath B, Pearce C, Browning C, Mazza D. After-hours medical deputising service use by older people. Med J Aust 2016; 205 397–402.
| After-hours medical deputising service use by older people.Crossref | GoogleScholarGoogle Scholar |
[23] Lindstrom SJ, Nagalingam V, Newnham HH. Impact of the 2009 Melbourne heatwave on a major public hospital. Intern Med J 2013; 43 1246–50.
| Impact of the 2009 Melbourne heatwave on a major public hospital.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC2c7nt1SmsQ%3D%3D&md5=2e483fe80ffd5ea9cef2dcb448d81959CAS |
[24] Turner LR, Connell D, Tong S. The effect of heat waves on ambulance attendances in Brisbane, Australia. Prehosp Disaster Med 2013; 28 482–7.
| The effect of heat waves on ambulance attendances in Brisbane, Australia.Crossref | GoogleScholarGoogle Scholar |
[25] Dolton P, Pathania V. Can increased primary care access reduce demand for emergency care? Evidence from England’s 7-day GP opening. J Health Econ 2016; 49 193–208.
| Can increased primary care access reduce demand for emergency care? Evidence from England’s 7-day GP opening.Crossref | GoogleScholarGoogle Scholar |
[26] Garth B, Temple-Smith M, Clark M, Hutton C, Deveny E, Biezen R, Pirotta M. Managing same day appointments: a qualitative study in Australian general practice. Aust Fam Physician 2013; 42 238–43.
[27] Lane R, Russell G, Bardoel EA, Advocat J, Zwar N, Davies PGP, Harris MF. When colocation is not enough: a case study of General Practitioner Super Clinics in Australia. Aust J Primary Health 2016;
| When colocation is not enough: a case study of General Practitioner Super Clinics in Australia.Crossref | GoogleScholarGoogle Scholar |
[28] Lee A, Lau FL, Hazlett CB, Kam CW, Wong P, Wong TW, Chow S. Factors associated with non-urgent utilization of accident and emergency services: a case-control study in Hong Kong. Soc Sci Med 2000; 51 1075–85.
| Factors associated with non-urgent utilization of accident and emergency services: a case-control study in Hong Kong.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3cvltVCisg%3D%3D&md5=3446c3579d3327b198c3d1b4feeb123bCAS |
[29] Carret ML, Fassa AG, Kawachi I. Demand for emergency health service: factors associated with inappropriate use. BMC Health Serv Res 2007; 7 131
| Demand for emergency health service: factors associated with inappropriate use.Crossref | GoogleScholarGoogle Scholar |
[30] Arendts G, Howard K. The interface between residential aged care and the emergency department: a systematic review. Age Ageing 2010; 39 306–12.
| The interface between residential aged care and the emergency department: a systematic review.Crossref | GoogleScholarGoogle Scholar |
[31] Honigman LS, Wiler JL, Rooks S, Ginde AA. National study of non-urgent emergency department visits and associated resource utilization. West J Emerg Med 2013; 14 609–16.
| National study of non-urgent emergency department visits and associated resource utilization.Crossref | GoogleScholarGoogle Scholar |
[32] DeVries A, Li CH, Sridhar G, Hummel JR, Breidbart S, Barron JJ. Impact of medical homes on quality, healthcare utilization, and costs. Am J Manag Care 2012; 18 534–44.
[33] Janamian T, Jackson CL, Glasson N, Nicholson C. A systematic review of the challenges to implementation of the patient-centred medical home: lessons for Australia. Med J Aust 2014; 201 S69–73.
| A systematic review of the challenges to implementation of the patient-centred medical home: lessons for Australia.Crossref | GoogleScholarGoogle Scholar |
[34] Williams ID, O’Doherty LJ, Mitchell GK, Williams KE. Identifying unmet needs in older patients: nurse–GP collaboration in general practice. Aust Fam Physician 2007; 36 772–6.
[35] Arain M, Nicholl J, Campbell M. Patients’ experience and satisfaction with GP led walk-in centres in the UK; a cross sectional study. BMC Health Serv Res 2013; 13 142
| Patients’ experience and satisfaction with GP led walk-in centres in the UK; a cross sectional study.Crossref | GoogleScholarGoogle Scholar |
[36] Wang M, Wild S, Hilfiker G, Chmiel C, Sidler P, Eichler K, Rosemann T, Senn O. Hospital-integrated general practice: a promising way to manage walk-in patients in emergency departments. J Eval Clin Pract 2014; 20 20–6.
| Hospital-integrated general practice: a promising way to manage walk-in patients in emergency departments.Crossref | GoogleScholarGoogle Scholar |
[37] Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center. J Hosp Med 2015; 10 419–24.
| The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center.Crossref | GoogleScholarGoogle Scholar |
[38] Hunchak C, Tannenbaum D, Roberts M, Shah T, Tisma P, Ovens H, Borgundvaag B. Closing the circle of care: implementation of a web-based communication tool to improve emergency department discharge communication with family physicians. CJEM 2015; 17 123–30.
| Closing the circle of care: implementation of a web-based communication tool to improve emergency department discharge communication with family physicians.Crossref | GoogleScholarGoogle Scholar |
[39] Harvey D, Foster M, Strivens E, Quigley R. Improving care coordination for community-dwelling older Australians: a longitudinal qualitative study. Aust Health Rev 2016;
| Improving care coordination for community-dwelling older Australians: a longitudinal qualitative study.Crossref | GoogleScholarGoogle Scholar |
[40] May-Miller H, Hayter J, Loewenthal L, Hall L, Hilbert R, Quinn M, Pearson N, Patel A, Law R. Improving the quality of discharge summaries: implementing updated Academy of Medical Royal Colleges standards at a district general hospital. BMJ Qual Improv Report 2015; 4 u207268.w2918
[41] Maurice A, Chan S, Pollard C, Kidd R, Ayre S, Ward H, Walters D. Improving the quality of hospital discharge summaries utilising an electronic prompting system. BMJ Qual Improv Report 2014; 03 u200548.w2201
[42] Belleli E, Naccarella L, Pirotta M. Communication at the interface between hospitals and primary care: a general practice audit of hospital discharge summaries. Aust Fam Physician 2013; 42 886–90.
[43] Nagree Y, Gosbell A, McCarthy S, Moore K, Mountain D. Determining the true burden of general practice patients in the emergency department: getting closer. Emerg Med Australas 2013; 25 487–90.
| Determining the true burden of general practice patients in the emergency department: getting closer.Crossref | GoogleScholarGoogle Scholar |
