Jones Aaron, Watt Jennifer A, Maclagan Laura C, Swayze Sarah, Jaakkimainen Liisa, Schull Michael J, Bronskill Susan E
Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
ICES, Toronto, Ontario, Canada.
J Am Geriatr Soc. 2023 Dec;71(12):3731-3743. doi: 10.1111/jgs.18457. Epub 2023 Jun 14.
Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits.
We used health administrative databases to conduct a population-based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community-dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk.
Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low-income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines.
History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia-friendly and geriatric-focused EDs. Collaborative medication review in the ED and closer follow-up and engagement with community supports could improve patient care and experience.
关于与急诊科（ED）复诊相关的因素及其对改善痴呆症护理的影响的研究尚属空白。本研究的目的是探讨痴呆症老年患者的个体特征与急诊科复诊之间的关联。
我们利用卫生行政数据库，在加拿大安大略省对患有痴呆症的老年人进行了一项基于人群的回顾性队列研究。我们纳入了2010年4月1日至2019年3月31日期间前往急诊科就诊并出院回家的66岁及以上的社区居住成年人。我们记录了基线就诊后一年内的所有急诊科就诊情况。我们使用复发事件Cox回归来研究重复急诊科就诊与个体临床、人口统计学和卫生服务使用特征之间的关联。我们拟合条件推断树以确定最重要的因素并定义不同风险的亚组。
我们的队列包括175,863名患有痴呆症的老年人。基线前一年的急诊科使用与复诊的关联最强（3次及以上与0次调整后风险比（aHR）：1.92（1.89，1.94），2次与0次aHR：1.45（1.43，1.47），1次与0次aHR：1.23（1.21，1.24））。条件推断树利用急诊科就诊史和合并症计数来定义12个亚组，每年的急诊科复诊率从0.79到7.27不等。高风险组的老年人更有可能居住在农村和低收入地区，并且抗惊厥药、抗精神病药和苯二氮䓬类药物的使用频率更高。
急诊科就诊史可能是识别能从额外干预和支持中受益的痴呆症老年患者的有用指标。相当一部分患有痴呆症的老年人有复诊模式，可能会从对痴呆症友好且以老年病为重点的急诊科中受益。急诊科的协作药物审查以及与社区支持的更密切随访和参与可以改善患者护理和体验。
