Balancing Evidence and Economics While Adapting Emergency Medicine to the 21st Century’s Geriatric Demographic Imperative

Abstract

Emergency department (ED) care for older Americans has reached a breaking point: Over 50 million U.S. adults ≥65 years old (“older adults”) currently account for one in five ED visits and ~50% of hospital admissions each year.1, 2 The projected growth of the number of U.S. older adults3 will further strain the capacity of the U.S. health care system to meet their complex care needs (Figure 1).4 Several factors are fueling this growth of geriatric emergency medicine: First, the ranks of fellowship-trained geriatricians in the United States has steadily declined5 despite economic and population models 27 years ago predicting inadequate numbers of geriatricians by 2030.6 Lacking rapid access to primary care or geriatrics and accelerated by acute diseases and injuries associated with aging, ED visits for older adults will continue to increase1. Second, inadequate access to primary care or geriatricians drives the upward trend in potentially preventable ED visits for ambulatory care sensitive conditions as measured using the Agency for Healthcare Research and Quality Prevention Quality Indicators.7 National Hospital and Ambulatory Care Survey data from 2001 to 2010 demonstrate that approximately 75% of ED visits by older adults did not involve life-threatening emergencies or critical illnesses.2 Third, one-third of all ED visits for older adults result in a non–intensive care unit admission independent of clinical acuity and the likelihood of admission increases with age.2 Yet, 60% of potentially preventable hospital admissions involve older adults.8 ED visits and hospital admissions, particularly those that are potentially preventable, are associated with loss of mobility, function, and independence, beyond that expected among comparable older adults who did not have an ED visit or a hospital stay.9 In summary, improving emergency care for older adults has demographic, pragmatic, ethical, and economic imperatives to proceed. Although Southerland’s economic analysis may not resonate with all institutions, her work nonetheless serves as an example of how one ED marshaled resources to improve care quality for their older patient population and created an effective model within their care environment. While their exact program may not be easily replicated, their principles can be. We recommend following Southerland’s steps: Know your patient population and understand the limits of your institution’s support, assess your patients’ greatest needs, identify one or two innovations that may create a meaningful change in the patients’ outcome, and develop a modest program that not only is economically palatable to your institution but also one where you more likely to demonstrate success. As society strives to improve geriatric emergency care for older adults, remember the mantra that doing something small and well is often better than doing nothing at all when suboptimal outcomes are being identified. Emergency medicine must do all it can—now and in the future—to ensure that routine emergency care provides patient-centered, geriatric-sensitive, high-quality, and appropriately cost-conscious care to older adults.

Topics & Concepts