Urgent and non-emergent telehealth care for seniors: Findings from a multi-site impact study.

INTRODUCTION: The global pandemic has raised awareness of the need for alternative ways to deliver care, notably telehealth. Prior to this study, research has been mixed on its effectiveness and impact on downstream utilization, especially for seniors. Our multi-institution study of more than 300,000 telehealth visits for seniors evaluates the clinical outcomes and healthcare utilization for urgent and non-emergent symptoms. METHODS: We conducted a retrospective cohort study from November 2015 to March 2019, leveraging different models of telehealth from three health systems, comparing them to in-person visits for urgent and non-emergent needs of seniors based on International Classification of Diseases, 10th edition diagnoses. The study population was adults aged 60 years or older who had access to telehealth and were affiliated with and resided in the geographic region of the healthcare organization providing telehealth. The primary outcomes of interest were visit resolution and episodes of care for those that required follow-up. RESULTS: In total, 313,516 telehealth visits were analysed across three healthcare organizations. Telehealth encounters were successful in resolving urgent and non-emergent needs in 84.0-86.7% of cases. When visits required follow-up, over 95% were resolved in less than three visits for both telehealth and in-person cohorts. DISCUSSION: While in-person visits have traditionally been the gold standard, our results suggest that when deployed within the confines of a patient's existing primary care and health system provider, telehealth can be an effective alternative to in-person care for urgent and non-emergent needs of seniors without increasing downstream utilization.

Reach and Adoption of a Geriatric Emergency Department Accreditation Program in the United States.

STUDY OBJECTIVE: The objectives of this study were to describe the reach and adoption of Geriatric Emergency Department Accreditation (GEDA) program and care processes instituted at accredited geriatric emergency departments (EDs). METHODS: We analyzed a cross-section of a cohort of US EDs that received GEDA from May 2018 to March 2021. We obtained data from the American College of Emergency Physicians and publicly available sources. Data included GEDA level, geographic location, urban/rural designation, and care processes instituted. Frequencies and proportions and median and interquartile ranges were used to summarize categorical and continuous data, respectively. RESULTS: Over the study period, 225 US geriatric ED accreditations were issued and included in our analysis-14 Level 1, 21 Level 2, and 190 Level 3 geriatric EDs; 5 geriatric EDs reapplied and received higher-level accreditation after initial accreditation at a lower level. Only 9 geriatric EDs were in rural regions. There was significant heterogeneity in protocols enacted at geriatric EDs; minimizing urinary catheter use and fall prevention were the most common. CONCLUSION: There has been rapid growth in geriatric EDs, driven by Level 3 accreditation. Most geriatric EDs are in urban areas, indicating the potential need for expansion beyond these areas. Future research evaluating the impact of GEDA on health care utilization and patient-oriented outcomes is needed.

WITHDRAWN: Urgent and non-emergent telehealth care for seniors: Findings from a multi-site impact study.

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Older adult visits to the emergency department for ambulatory care sensitive conditions.

OBJECTIVES: Ambulatory-care-sensitive conditions (ACSCs) represent emergency department (ED) visits and hospital admissions that might have been avoided through earlier primary care intervention. We characterize the current frequency and cost of ACSCs among older adults (≥65 years of age) in the ED. METHODS: This study is a retrospective analysis of Centers for Medicare and Medicaid Services (CMS) national claims data distributed by the Research Data Assistance Center, a CMS contractor based at the University of Minnesota. We analyzed outpatient ED-based national claims data for visits made by traditional fee-for-service (FFS) Medicare beneficiaries in 2016. ACSCs were identified according to the Agency for Healthcare Research and Quality's Prevention Quality Indicators criteria, which require that the ACSC be the primary diagnosis for the visit. Analysis was done in Alteryx and R. RESULTS: We documented nearly 1.8 million ACSC ED visits in 2016, finding that ≈10.6% of all ED visits by older adult FFS Medicare beneficiaries were associated with an ACSC. ACSC ED visits resulted in admission more often (39.7%) than non-ACSC ED visits (23.9%). Notably, 83% of patients with short-term complications from diabetes were admitted. CONCLUSIONS: ED visits for a primary diagnosis of an ACSC highlight opportunities to improve access to preventive care, particularly earlier recognition and treatment of patients' deteriorating conditions that could have potentially precluded the need for the ED visit. An opportunity exists to leverage ED-based initiatives during an ACSC ED visit to support appropriate community and care transitions of these high-risk patients.

Association of dementia diagnosis with urinary tract infection in the emergency department.

OBJECTIVES: Overdiagnosis of urinary tract infections (UTI) among people living with dementia is a nationally recognized problem associated with morbidity from antibiotics as well as multidrug-resistant bacteria. However, whether this problem also exists in the emergency department (ED) is currently unknown. METHODS: To examine the association between dementia and UTI diagnosis in the ED we performed a retrospective analysis of Medicare beneficiaries older than 65 years old who presented to an ED in 2016. A diagnosis of UTI was present in 58,580 beneficiaries, and 321,479 beneficiaries without a diagnosis of UTI served as the comparison group. Our logistic regression model controlled for dementia, older age, female sex, Medicaid status, skilled nursing facility residence, history of prostate cancer, recent urinary catheter use, recurrent UTI, and multiple comorbidities. RESULTS: In our model, people living with dementia had over twice the odds (odds ratio = 2.27, 95% confidence interval = 2.21, 2.33) of being diagnosed with a UTI in the ED compared to those without dementia despite their lower prevalence of symptoms and signs localizing to the genitourinary tract (3.8% vs 8.9%, respectively). CONCLUSION: This is the first study from a national database that examines the association of dementia with UTI diagnosis among older adults who visit the ED. Our study could not establish whether the UTI diagnoses in the ED were accurate but does imply a disproportionate burden of UTI diagnoses in people living with dementia despite their lower prevalence of clinical criterion. Antimicrobial stewardship in the ED should address the complexity of UTI diagnosis in dementia.

30-Day Emergency Department Revisit Rates among Older Adults with Documented Dementia.

OBJECTIVES: Published literature on national emergency department (ED) revisit rates among older adults with dementia is sparse, despite anecdotal evidence of higher ED utilization. Thus we evaluated the odds ratio (OR) of 30-day ED revisits among older adults with dementia using a nationally representative sample. DESIGN: We assessed the frequency of claims associated with a 30-day ED revisit among Medicare beneficiaries with and without a dementia diagnosis before or at index ED visit. We used a logistic regression model controlling for dementia, age, sex, race, region, Medicaid status, transfer to a skilled nursing facility after ED, primary care physician use 12 months before index, and comorbidity. SETTING: A nationally representative sample of claims data for Medicare beneficiaries aged 65 and older who maintained continuous fee-for-service enrollment during 2015 and 2016. Only outpatient claims associated with an ED visit between January 2016 and November 2016 were included as a qualifying index encounter. PARTICIPANTS: We identified 240 249 patients without dementia and 54 622 patients for whom a dementia code was recorded in the year before the index encounter in 2016. RESULTS: Our results indicate a significant difference in unadjusted 30-day ED revisit rates among those with an ED dementia diagnoses (22.0%) compared with those without (13.9%). Our adjusted results indicated that dementia is a significant predictor of 30-day ED revisits (P < .0001). Those with a dementia diagnosis at or before the index ED visit were more likely to have experienced an ED revisit within 30 days (OR = 1.27; 95% confidence interval = 1.24-1.31). CONCLUSION: Dementia diagnoses were a significant predictor of 30-day ED revisits. Further research should assess potential reasons why dementia is associated with markedly higher revisit rates, as well as opportunities to manage and transition dementia patients from the ED back to the community more effectively. J Am Geriatr Soc 67:2254-2259, 2019.

Association Between Physical Therapy in the Emergency Department and Emergency Department Revisits for Older Adult Fallers: A Nationally Representative Analysis.

OBJECTIVES: To determine whether providing physical therapy (PT) services in the emergency department (ED) improves outcomes for older adults who fall. DESIGN: We used Medicare claims data to examine differences in recurrent fall-related ED revisit rates of older adults who presented to the ED for a ground-level fall and whether they received PT services in the ED. Our logistic regression model controlled for age, sex, Medicaid eligibility, acute injury, and certain known chronic comorbidities associated with risk of falling. SETTING: We analyzed national 2012-13 Medicare claims data for individuals aged 65 and older. PARTICIPANTS: This was a claims-based analysis. We defined an index visit as any ED claim that included an International Classification of Diseases, Ninth Revision, Clinical Modification E-Code indicating a ground-level fall. Visits resulting in admission were excluded, as were claims associated with an individual who died during follow-up; 17,975 of the 560,277 claims for eligible outpatient index visits included revenue center codes for PT services. MEASUREMENTS: We calculated the proportion of index visits associated with a fall-related ED revisit within 30 and 60 days and assessed differences in these proportions between individuals who did and did not receive PT services in the ED. RESULTS: Receiving PT services in the ED during an index visit for a ground-level fall was associated with a significantly lower likelihood of a fall-related ED revisit within 30 days (odds ratio (OR)=0.655, p<.001) and 60 days (OR=0.684, p<.001). CONCLUSION: Expanding PT services in the ED may reduce future fall-related ED use of older adults. Additional analyses could assess characteristics of individuals receiving PT in the ED and follow-up PT use after discharge. J Am Geriatr Soc 66:2205-2212, 2018.

Delirium as a predictor of mortality in US Medicare beneficiaries discharged from the emergency department: a national claims-level analysis up to 12 months.

BACKGROUND: Delirium is common among seniors discharged from the emergency department (ED) and associated with increased risk of mortality. Prior research has addressed mortality associated with seniors discharged from the ED with delirium, however has generally relied on data from one or a small number of institutions and at single time points. OBJECTIVES: Analyse mortality rates among seniors discharged from the ED with delirium up to 12 months at the national level. DESIGN: Retrospective cohort study. SETTING: Analysed data from the Centers for Medicare & Medicaid Services limited data sets for 2012-2013. PARTICIPANTS: Medicare fee-for-service beneficiaries aged 65 years or older discharged from the ED. We focused on new incident cases of delirium, patients with any prior claims for delirium, hospice claims or end-stage renal disease were excluded. Sample size included 26 245 delirium claims, and a randomly selected sample of 262 450 controls. OUTCOME MEASURES: Mortality within 12 months after discharge from the ED, excluding patients transferred or admitted as inpatients. RESULTS: Among all beneficiaries, 46 508 (16.1%) died within 12 months, of which 39 404 (15.0%) were in the non-delirium (ie, control group) and 7104 (27.1%) were in the delirium cohort, respectively. Mortality was strongest at 30 days with an adjusted HR of 4.82 (95% CI 4.60 to 5.04). Over time, delirium was consistently associated with increased mortality risk compared with controls up to 12 months (HR 2.07; 95% CI 2.01 to 2.13). Covariates that affected mortality included older age, comorbidity and presence of dementia. CONCLUSIONS: Our results demonstrate delirium is a significant marker of mortality among seniors in the ED, and mortality risk is most salient in the first 3 months following an ED visit. Given the significant clinical and financial implications, there is a need to increase delirium screening and management within the ED to help identify and treat this potentially fatal condition.