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. 2023 Dec 18;149(1):32–44. doi: 10.1093/bmb/ldad033

Variations in older people’s emergency care use by social care setting: a systematic review of international evidence

Kelly Brotherhood 1,✉, Ben Searle 2, Gemma Frances Spiers 3, Camila Caiado 4, Barbara Hanratty 5
PMCID: PMC10938536  PMID: 38112600

Abstract

Background

Older adults’ use of social care and their healthcare utilization are closely related. Residents of care homes access emergency care more often than the wider older population; however, less is known about emergency care use across other social care settings.

Sources of data

A systematic review was conducted, searching six electronic databases between January 2012 and February 2022.

Areas of agreement

Older people access emergency care from a variety of community settings.

Areas of controversy

Differences in study design contributed to high variation observed between studies.

Growing points

Although data were limited, findings suggest that emergency hospital attendance is lowest from nursing homes and highest from assisted living facilities, whilst emergency admissions varied little by social care setting.

Areas timely for developing research

There is a paucity of published research on emergency hospital use from social care settings, particularly home care and assisted living facilities. More attention is needed on this area, with standardized definitions to enable comparisons between studies.

Keywords: older people, social care, emergency care, hospital attendance, hospital admissions

Introduction

Demand for emergency care in England has risen over the past decade.1 The older population, who are living with an increasing number of complex care needs, has seen a larger increase in emergency hospital attendance in recent years than any other age group.2–4 Older people are also more likely to be admitted to hospital as an emergency after visiting the Emergency Department in comparison with other age groups.5 Whilst emergency hospital-based care is often the most appropriate method of administering care, visits to the Emergency Department can have adverse consequences for older people. Older people admitted to hospital are vulnerable to infection, face an increased risk of delirium and often see a decline in their health and wellbeing post-discharge from hospital.6 Therefore, it is important that older people attend the Emergency Department only when necessary.

Older people access emergency care from a variety of settings in the community. Care home residents’ use of emergency care is disproportionately high, in comparison with the wider older population.7 However, patterns of Emergency Department use are less clear from other social care settings. As the size of our older population grows,8 demand for social care is expected to rise, in terms of the number of people requiring care and the complexity of their care needs.9 This is particularly concerning in some regions of England, such as the North East, where the number of care home beds is declining.10 Here, home-based care and assisted living services will play a key role in supporting the needs of the older population.

Many visits to the Emergency Department made by the older population are thought to be for conditions that could potentially be managed outside of a hospital setting. To support policy efforts to reduce avoidable demand for emergency care, both in England and for many other Western governments, interventions must be timely and targeted at the right populations. Current approaches focus on delivering urgent healthcare in community settings, including hospital at home services11 and urgent community response teams.12 To optimize these approaches, it is important to understand which individuals are the highest users of emergency care.

To address this gap, a systematic review of international evidence was conducted. This review aimed to: (i) quantify emergency hospital attendances (defined as visits to the Emergency Department) and admissions (defined as subsequent admission to hospital) from the older population receiving different types of social care; and (ii) identify which social care setting made the greatest contribution of emergency hospital attendances and admissions.

Methods

The protocol for this systematic review is registered on PROSPERO (ID CRD42022319784). The methods are reported in accordance with the PRISMA guidance and checklist.13

Search strategy

A search strategy was developed and refined for the population (older people aged 60+), exposure (the type of social care received) and the two outcomes of interest (average number of emergency hospital attendances and admissions per person per year). Searches were restricted to observational studies published from 2012 onwards in high-income countries. Searches were carried out in MEDLINE, EMBASE (via OVID), CINAHL (via EBSCO), Health Management Information Consortium (HMIC), Scopus and SSCI Online (via Web of Science). Three sources of grey literature were also searched: The Health Foundation, The King’s Fund and Nuffield Trust. Searches were conducted in February 2022.

Review criteria

Titles and abstracts of all search records were screened for relevance. The full texts of selected records were retrieved and assessed against the review criteria (Table 1). In both stages of screening, all records were screened independently by the primary researcher and one co-author; disagreements were resolved through consensus. Records were managed in Rayyan, an online software platform to manage screening in systematic reviews.14

Table 1.

Systematic review criteria

Parameter Inclusion criteria Exclusion criteria
Population Older people, aged 60+, who received a form of social care Studies which exclude individuals who did not receive emergency care
Exposure (Type of social care received) Type of social care received, including nursing homes, residential homes (without nursing), home-based social care (domiciliary care services referred to as ‘home care’), supported living services (referred to as ‘assisted living’) and support from an informal (not paid-for) carer, such as a relative or friend Studies based in an Emergency Department setting reporting the proportion of individuals receiving various types of social care
Comparator Any comparator (studies comparing multiple settings of care) and no comparator (studies in a single setting of care)
Outcomes Two outcomes are included: (i) the average number of emergency hospital attendances per person per year and (ii) the average number of emergency hospital admissions per person per year
Studies which reported the number of emergency hospital attendances and the number of emergency hospital admissions, in addition to the total population size, were included as the desired outcomes could be derived
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Data extraction

A data extraction form was developed, piloted and refined. Study characteristics (location, study period), population attributes (age, size of population, diagnoses, number of co-morbidities and proxy measures of care needs), exposures and outcomes of interest (including outcome definitions and 95% confidence intervals) were extracted where available, into a Microsoft Excel spreadsheet by one researcher. Data extraction was checked for accuracy by a second researcher for 50% of studies.

Quality assessment

As this review is focused on observational studies, study quality was assessed using the National Institute of Health Quality Assessment’s Tool for Observational Cohort and Cross-Sectional Studies. One researcher assessed the quality of each study using 10 relevant domains of this tool, noting whether each statement was given ‘yes’, ‘no’, ‘cannot determine’ or ‘not applicable’ answers.

Synthesis

A narrative synthesis was conducted, supported by forest plots. It was not possible to pool data for meta-analysis, due to heterogeneity in study design. The forest plots were used to illustrate the average number of emergency attendances and admissions per person per year, across different social care settings. Studies where Poisson confidence intervals could be derived were included in the plots. The average number of emergency attendances and admissions per person was derived for some studies (indicated in Table 2) by dividing the number of emergency hospital attendances or admissions by the study population size. In some instances, the number of emergency hospital attendances or admissions was derived using the reported percentage of the population who had an emergency attendance or admission. Data extracted where the study period was shorter or longer than 12 months was adjusted, to estimate the number of attendances or admissions over 12 months. Each forest plot was assessed visually to describe how emergency attendances or admissions varied between social care settings. Possible causes of heterogeneity between studies were explored by mapping differences in study design and study populations. Outliers were assessed on an individual basis, to identify any possible drivers of variation.

Table 2.

Summary of all study characteristics

Paper Population characteristics Study methodology Indicators of level of need reported?
County Sample size—analysed Average age Health-related inclusion criteria Study period Study setting Study design Derived data Is attendance & admission mutually exclusive? Are repeated attendances or admissions included? Are temporary residents included?
Amador 2014 England 133 86.2 Dementia 12 months 6 residential homes Prospective cohort Rate of attendance/admission Yes No Yes Co-morbidities
Bardsley 2012 England 133 055 82.2 None 12 months Health and local authority funded social care in four areas Retrospective cohort Number of attendances/admissions Yes Yes No None
Blackburn 2016 USA 2582 80 None 21 months Nursing homes, home health recipients Matched retrospective cohort Number of attendances/admissions No Yes Yes Mobility, toileting independence
de Souto Barreto 2013 France 5684 87 53.2% of sample had dementia/ suspected dementia 12 months 175 nursing homes Cross-sectional Rate of attendance/admission No No No Activities of Daily Living score, number of diseases
Dubucs 2018 France 5926 86 None 12 months 175 nursing homes Cross-sectional Rate of attendance/admission No Yes No None
Fassmer 2020 Germany 1665 80.5 None 24 months Nursing homes Retrospective cohort No Yes Yes No Level of care dependency, co-morbidities
Givens 2012 USA 323 85.3 Advanced dementia 18 months Nursing homes Prospective cohort Rate of attendance/admission Yes Yes No None
Gruneir 2016 Canada 71 780 84.4 None 12 months Nursing homes Retrospective cohort Rate of attendance/admission No No No Activities of daily living score, cognitive performance scale
Hongli 2018 Singapore 202 78.9 None 12 months 1 nursing home Retrospective cohort No Yes Yes No Functional status
Hua 2021 USA 293 336 Not reported (sample are aged 65+) None 12 months Assisted living facilities Retrospective cohort Population size No Yes Yes None
Inacio 2021 Australia 116 192 85 (median age) None 48 months Residential aged care facilities Retrospective cohort N/A – not used in analysis No No No Dementia, frailty
Kihlgren 2014 Sweden 719 85.8 None 12 months Nursing homes Cross-sectional follow up Rate of attendance/admission No Yes Yes Cognitive performance scale, number of diseases
Kirsebom 2014 Sweden 431 87 None 9 months Nursing homes Retrospective cohort N/A – not used in analysis Yes Yes Yes None
LaMantia 2016 USA 4491 79.6 None 12 months Nursing homes Retrospective cohort N/A – not used in analysis Yes No No Dementia severity
McGregor 2014 Canada 13 140 83.1 None 36 months Nursing homes Retrospective cohort Rate of attendance/admission No Yes Yes None
McGregor 2014 Canada 13 051 Assisted living: 81.5 Nursing home: 83.1 None 36 months Nursing homes, assisted living Retrospective cohort No No Yes No None
Mondor 2017 Canada 30 112 83 Dementia 12 months Home care Retrospective cohort Rate of attendance/admission Yes No No Multimorbidities
Neufeld 2016 Canada 2061 Not reported None 12 months Home care Cross sectional N/A – not used in analysis Yes Yes Yes Activities of daily living hierarchy scale score
Stephens 2012 USA 132 753 Not reported None 12 months Nursing homes Cross sectional Rate of attendance/admission No No Yes Activities of daily living impairment, level of cognitive impairment
Stephens 2014 USA 112 412 Not reported None 12 months Nursing homes Retrospective cohort Number of attendances/admissions Yes Yes Yes Activities of daily living score
Walker 2014 England 63 81.3 Parkinson’s disease 24 months Residential homes Retrospective cohort N/A – not used in analysis Yes Yes No Mobility
Wolters 2019 England 195 296 Residential home: 85.6 Nursing home: 84.7 None 12 months Nursing homes, residential homes Retrospective cohort No No Yes No Charlson index, Elixhauser co-morbidity index, frailty-related conditions
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Results

A total of 8937 records were identified for title and abstract screening, of which 124 were flagged for full-text screening. Twenty-two studies met the inclusion criteria for this review (Fig. 1).

Fig. 1.

Fig. 1

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PRISMA flowchart, illustrating study selection process.

Quality assessment

Fifteen of the twenty-two included studies were rated as ‘good’ quality15–29 and seven studies were rated ‘fair’.7,30–35 Reasons for these ratings included omissions in reporting overall sample size (32) and confidence intervals for the metric of interest7,30,32–35; and studies with a participation rate below 50%.31 One study was excluded from the synthesis due to a short follow-up period.35 We judged that risk of reporting bias was low. The results of the quality assessment are included in the Supplementary Materials.

Forest plots

Forest plots were generated to visualize the average number of hospital attendances and admissions, and associated 95% confidence intervals, for each study. Three high quality studies were excluded from the forest plots because the required outcome data were not reported.24,28,29 One paper was excluded from the forest plot presenting emergency hospital attendances due to missing data, however, it was possible to include this study in the forest plot pertaining to emergency hospital admissions.23

Emergency hospital attendances

The average number of emergency hospital attendances per person per year was reported or derived in 16 studies. Of these 16 studies, 4 studies compared attendances between 2 or more social care settings.7,15,26,31 Each of these 4 studies compared emergency attendances in nursing homes with either residential homes,7 assisted living facilities26 or care received in the home.15,31 One of these studies did not distinguish between different types of care home.15 The remaining 12 studies reported attendances in a single setting of care: nursing homes16–20,22,25,33,34; residential homes30; home care27; and an assisted living facility.21 All 16 studies were judged to have a low risk of bias.

Rates of emergency hospital attendance were highest in assisted living facilities and lowest in nursing homes (Fig. 2). However, there was high variation in the average number of emergency hospital attendances, both between different settings of care and within the same setting of care. Reasons for this heterogeneity may be explained by differences in study populations and study design. Analysis of the group of comparator studies offered another approach to compare different settings of care. Emergency hospital attendance was lower in nursing homes in comparison with residential homes 7, assisted living facilities 26 and home health services 31. Similarly, emergency hospital attendances were lower from care homes compared with home care services 15. Reported differences in hospital attendance rates were small, with differences between care settings ranging from 0.1 to 0.61 additional hospital attendances per person per year.

Fig. 2.

Fig. 2

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Forest plot illustrating the average number of emergency hospital attendances per person per year and calculated 95% confidence intervals for each included study. Studies marked with an asterisk (*) compared two or more settings of social care.

Emergency hospital admissions

Nine studies reported the average number of emergency hospital admissions per person per year. Three studies compared admissions in nursing homes against residential homes,7 assisted living facilities26 or home care services.15 One study did not distinguish between different types of care home.15 Seven studies described emergency admissions in a single care setting: nursing homes,18,19,23,32,34 residential homes30 and home care.27 All studies were judged to have a low risk of bias. The average number of emergency hospital admissions per person per year for each study is presented in Figure 3.

Fig. 3.

Fig. 3

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Forest plot illustrating the average number of emergency hospital admissions per person per year and calculated 95% confidence intervals for each included study. Studies marked with an asterisk (*) compared two or more settings of social care.

We found no clear relationship between the number of emergency hospital admissions and settings of social care. Most of the variation seen in Figure 3 is driven by two studies (Stephens 2014 and Fassmer 2020), however closer inspection of these studies did not indicate what may be driving a higher number of emergency hospital admissions within these populations. Analysis of the group of comparator studies indicated that emergency admissions are lower from nursing homes compared with residential homes7 and assisted living facilities.26 Admissions were also found to be lower from care homes than in home care settings.15

Heterogeneity between studies

The characteristics of each study are mapped out in Table 2. An assessment of the differences in study design and population characteristics was undertaken, to understand if there are factors other than setting of care which may be driving differences in the reported rates of emergency hospital attendance or admission.

Study populations varied based on their inclusion or exclusion of ‘short-term’ social care recipients. Some study populations were selected based on a diagnosis of dementia or cognitive impairment; others included all care recipients. Crucially, the included studies took place across eight countries, each with different systems of health and social care. Inconsistency in the reporting of population characteristics meant that, unfortunately, it was not possible to explore whether heterogeneity in the care needs (e.g. co-morbidities or pre-existing advanced care plans) of each study population may explain the variation in emergency admissions and attendances.

The measurement of the outcomes varied between studies. Some studies distinguished between emergency hospital attendances and admissions, while other studies did not. Higher emergency hospital attendance was expected in 10 studies that included individuals who were subsequently admitted to hospital in their estimates of emergency attendance. Furthermore, some studies did not account for repeat Emergency Department attendances and are therefore likely to underestimate emergency hospital attendance.

The lack of comparability between studies limits the conclusions we can draw. However, illustrating the study data in forest plots can help to reveal potential trends in emergency hospital attendance or admission across each setting of care.

Discussion

Summary of findings

This review explores existing data on the emergency care use of older people living in different settings of social care. We found limited data in care settings outside of nursing homes, including individuals receiving care at home or in assisted living facilities. No data were found pertaining to informal care. Although data are limited, there appears to be a higher number of emergency hospital attendances in assisted living facilities compared with nursing homes, suggesting that emergency attendance may vary according to the level of nursing input provided within the care setting. However, variation in emergency attendance was high between studies taking place within the same setting. Less variation was observed between emergency admissions across different settings of care, suggesting that once a threshold of severity is reached, there is consistency in hospital decision-making to admit patients.

Comparison with other work

Previous research has suggested that the presence of registered nurses within a social care setting can moderate ambulance call rates and hospital admissions.25,36,37 Recent research demonstrated that people with dementia in the last year of their life, who live in a local authority with more nursing home beds, have fewer visits to the Emergency Department than people living in local authorities with a lower number of nursing home beds.38 Our review suggests that emergency hospital attendances are lower in nursing homes in comparison with other care settings, including residential homes,7 assisted living facilities26 and home care services.15,31 This finding may be surprising, as one would expect individuals residing in an assisted living facility to have fewer complex care needs than individuals living in a nursing home, for example, and therefore one may be expect residents of assisted living facilities to require less hospital care. Previous authors have suggested several reasons why Emergency Department attendance is lower amongst nursing home residents in comparison with other care settings. Older people with higher health instability and cognitive impairment, who are more likely to live in a nursing home, are more likely to have a ‘do not hospitalize’ order, which consequently leads to lower rates of hospitalization.39 Another explanation is that health needs may be detected earlier in care settings with nursing. Similarly, staff in care facilities with access to nursing may be better equipped to manage patient health within the facility, and therefore may be less reliant on emergency care.7

Implications

Our review highlights a stark lack of data on emergency care use in social care settings outside of care homes. Of the six included studies that reported on emergency care use in settings other than care homes, five studies took place in the USA or Canada, where use of a minimum dataset in social care is common. One study highlights the potential of conducting analyses of linked health and social care data in England. However this study is limited to local authority-funded care and does not account for those who self-fund their care.15 Uptake of a minimum dataset in England, linked to health data, would enable further exploration on the needs and outcomes of these populations. Our review also highlights inconsistencies in reporting of population characteristics between studies. Consistent reporting of care needs would facilitate comparisons between studies.

Evidence presented in our review suggests that older people living in nursing homes visit the Emergency Department marginally less often than older people in other social care settings. However, an older person’s place of residence does not appear to influence the likelihood of them being admitted to hospital, after visiting the Emergency Department. Our review found that individuals who visit the Emergency Department but are not subsequently admitted to hospital are more likely to be living in social care settings without registered nurses on site, such as assisted living facilities. These individuals may benefit the most from targeting of community-based resources, such as district nurse and primary care input.

Strengths and limitations

A strength of this review is its inclusion of all social care settings, enabling us to identify a gap in our understanding of emergency care use in assisted living facilities and home care services. It is important that more research is conducted in these care settings, as we are becoming increasingly reliant on these settings of care to meet the needs of our older population. We also assessed outcomes specific to emergency care, which are neglected in the current literature. Drawing conclusions from our analysis was challenging, due to variation in study population characteristics and outcome definitions. Although variation in levels of emergency care use within a setting of social care is to be expected,20,23,25 some variation may be driven by differences in study design. A limitation of our approach was that differences in study design are not accounted for in our analysis. Unfortunately, this was not possible due to multiple drivers of variation and a relatively small group of included studies. Future evidence on emergency care use would benefit from consistency in outcome definitions and study design.

Unfortunately, it was not possible to account for differences in the care needs of each study population in our review. We extracted data for a variety of proxy measures of care need, but found that these metrics were not consistently reported. One of our included studies demonstrated that a group of individuals with mild cognitive impairment had greater use of emergency care than a group with severe cognitive impairment.34 This finding may reflect the findings of our review, as older people with severe cognitive impairment have higher social care needs and are therefore more likely to require nursing care than individuals with mild cognitive impairment. Further research would be needed to clarify how an individual’s level of care need impacts their use of emergency care. It is important to note that the included studies were published between 2012 and 2020, with data collected prior to the COVID-19 pandemic. It would be interesting to compare the results of this review with future studies, to determine how changes to the healthcare system such as increased hospital at home40 have impacted emergency hospital attendances.

Conclusions

This review highlights data gaps in the emergency care use of older people in social care, particularly in settings other than care homes. Despite data being limited, this review suggests that the level of nursing input within a social care setting moderates its contribution of emergency hospital attendances, whereby older people with access to nursing care are less likely to visit the Emergency Department than older people residing in assisted living facilities.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

Supplementary Material

BMB_Submission_Supplementary_Data_Revised_ldad033
bmb_submission_supplementary_data_revised_ldad033.docx (48.3KB, docx)

Contributor Information

Kelly Brotherhood, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK.

Ben Searle, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK.

Gemma Frances Spiers, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK.

Camila Caiado, Department of Mathematical Sciences, Mathematical Sciences & Computer Science Building, Durham University, Upper Mountjoy Campus, Stockton Road, Durham, DH1 3LE, UK.

Barbara Hanratty, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK.

Funding

This review was carried out as part of a PhD studentship with the Applied Research Collaboration in the North East and North Cumbria, funded by the National Institute for Health Research. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Conflict of interest statement

The authors have no potential conflicts of interest.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

BMB_Submission_Supplementary_Data_Revised_ldad033
bmb_submission_supplementary_data_revised_ldad033.docx (48.3KB, docx)

Data Availability Statement

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

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