Poor Physician Access Linked With Unplanned Return ED Visits Poor Physician Access Linked With Unplanned Return ED Visits

Difficulty in accessing a family physician is associated with a higher risk for unplanned return visits to the emergency department (ED) among patients aged 75 years and older, new data indicate.

In a prospective, observational study that included almost 2000 patients in this age group, 16% of participants attempted to contact their family physicians before their ED visits. Of this group, more than half reported having difficulty seeing their physicians for urgent problems, more than 40% had difficulty speaking with their family physicians by telephone, and more than one third had difficulty booking appointments for new health problems.

“Difficulty in accessing primary care was associated with a higher rate of return visits to the ED within an elderly population,” write study author Marc Afilalo, MD, director of the ED at Jewish General Hospital in Montréal, Quebec, and colleagues. “Therefore, community-based programs that target patient education and improved access to primary care are necessary not only for reducing return visits to the ED, but also for continuity of care and patient satisfaction.”

The study was published in the August issue of Canadian Family Physician.

Comorbidities Increased Risk

Researchers have estimated that half of Canadians aged 75 years or older use emergency services. Data indicate that the number of unplanned return visits to the ED is associated with increased functional decline and death. But the question of how patient access to primary care services affects unplanned ED return visits has received little attention, according to the investigators.

They conducted a multicenter study at three tertiary adult teaching hospitals in Montreal. From 2012 to 2014, they recruited patients aged 75 years and older who had visited the ED and who lived in their own homes or in an autonomous residence.

Investigators collected data through structured interviews, administrative databases, and medical chart reviews. They followed up with participants at 3 months by telephone. The study’s main outcome was return visit to the ED.

The researchers identified 4577 patients and included 1998 in their analysis. Of that total, 33% were 85 or older, 34% lived alone, and 91% had a family physician. Within 3 months, 562 patients (28%) had made 894 return visits to the ED.

Among patients aged 85 years or older (relative risk [RR] = 0.80), as well as those whose triage score was less severe (RR = 0.83) and those who were admitted during the index ED visit (RR = 0.76), rates of return ED visits were lower. Among patients who had trouble booking appointments with their family doctors to address new problems (RR = 1.19), as well as those who had made ED visits within the previous 6 months (RR = 1.47) or had a higher Charlson comorbidity index score (RR = 1.06 for every 1-unit increase), rates of return visits were higher.

Factors associated with a higher likelihood of return visits were visits to the ED in the previous 6 months (odds ratio [OR] = 2.11), increased Charlson comorbidity index score (OR = 1.41 for every 1-unit increase), and having received help from local community services (OR = 3.00).

Primary Care Access

The study suggests that improvements in primary care access are needed to decrease return visits to the ED, Samir Sinha, MD, DPhil, director of geriatrics at Mount Sinai and the University Health Network Hospitals in Toronto, Ontario, told Medscape Medical News. Sinha was not involved in the study.

Dr Samir Sinha

“It reminds us of the importance of having a strong primary care system,” he added. “Of this population, 91% had primary care providers. And what the paper demonstrates is that those who are having trouble accessing their primary care providers are more likely to be readmitted to an ED. We can only imagine how much worse the outcomes are for people who don’t have a primary care provider.”

Dr Mark Rosenberg

Patients are frequently advised to visit the ED when they contact their primary care providers, said Mark Rosenberg, PhD, professor of geography and planning and the Canada research chair in aging, health, and development at Queens University in Kingston, Ontario, told Medscape. He noted that primary care is organized as an appointment-based system. Rosenberg did not participate in the study.

“If I were to call my primary care provider in the middle of the afternoon and say that I have got chest pains, they are going to simply tell me to go to emergency,” said Rosenberg. “It is not just older people. Many people end up in the ED because they are told to go to the ED.”

Associations With Age

“The higher your Charlson comorbidity index, the more multiple, complex health issues you’re dealing with,” said Sinha. He added that the data suggest the frailty of the study population.

The association between age 85 years or older and a lower rate of a return ED visits might mean that the patient did not return to independent living after the ED visit, Rosenberg speculated. “If it’s a serious health problem, you’re more likely to end up going into long-term care at that stage, and you are not going back to living in the community in your home,” he said. “You’re likely going into some sort of transition care or alternative care.”

People aged 85 years or older who are hospitalized are more likely not to survive their index hospital admission, compared with patients who are aged 75 to 85 years. There would be no possibility that such patients would revisit the ED in the future, said Sinha.

Expanding Primary Care

The major solution to decreasing reliance on the ED lies in revamping primary healthcare so that it offers an expanded level of care and 24/7 access, said Rosenberg.

Providing continuity of care, identifying problems, and managing them in the community before they become urgent or require a hospitalization are priorities for primary care and will help shift away from return visits to the ED, which should be a last resort for patients, said Sinha.

Moreover, patients must be able to access primary care in various ways, be it a telephone consultation, a video consultation, or a face-to-face consultation, he added. Face-to-face consultations can take place in a provider’s office or even in a patient’s home when warranted, he said. “What we need to make sure is that all three types of consultations are available, so that people can actually get the most appropriate care at the time they’re calling.”

The study had no external funding. Afilalo, Sinha, and Rosenberg have disclosed no relevant financial relationships.

Can Fam Physician. 2022;68:599-606. Full text

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