Factors Associated with Re-attendance at Emergency Departments Among Older Adults: A Cross-Sectional Analytical Study

Abstract

Emergency department (ED) re-attendance among older adults is an increasing global concern, often reflecting gaps in chronic disease management, discharge planning, and continuity of care. This study aimed to determine the frequency of ED re-attendance and identify associated patient- and system-level factors. A cross-sectional analytical study was conducted between July 2023 and August 2024 across general and community hospitals. A total of 740 participants were selected using multi-stage sampling, comprising 400 older adult patients and 340 healthcare professionals. Data were collected from medical records and structured questionnaires. Descriptive statistics and multiple logistic regression were applied to identify factors linked to ED re-attendance within 60 days. Among older adults, 35% revisited the ED within 60 days post-discharge. Key factors significantly associated with re-attendance included prior ED visits (OR = 3.92; 95% CI: 2.11-7.31), hospitalization within the previous year (OR = 1.97; 95% CI: 1.15-3.38), no follow-up with specialists (OR = 2.27; 95% CI: 1.35-3.83), and treatment at M2-level hospitals (OR = 7.28; 95% CI: 3.62-14.64). Targeted strategies to improve discharge processes, ensure specialist follow-up, and enhance primary care coordination are essential to reduce potentially avoidable ED re-attendance among older adults.

• What we already know?

• ● Older adults experiencing emergency illnesses show a range of severity, with the majority of cases classified as urgent, non-urgent and emergent.

• ● Many older adult patients return to the emergency department (ED) for repeat treatment after discharge.

• ● Studies of re-attendance at emergency department for older adults are relatively scarce.

• What this study adds?

• ● This study reveal that older patients revisited the emergency department primarily due to exacerbations of chronic illnesses.

• ● Factors influencing readmissions included a history of prior ED visits and hospitalizations, as well as the level of care received during hospitalization.

• ● Findings of this study indicated that the critical necessity for optimized discharge planning and expanded patient education to mitigate recurrent emergency department visits and promote efficient emergency care management for older adults.

Introduction

About 70:30% of older adults have experienced emergencies as a result of illnesses and injuries sustained overseas, with chronic diseases or comorbidities accounting for the majority of these cases.^1,2 It was discovered that older adults in Thailand were utilizing emergency medical care. High blood pressure (57.8%), diabetes (37.1%), joint pain, osteoarthritis, rheumatoid arthritis (18.1%), heart disease, leaky heart valve (15.3%), and paralysis (9%), among other underlying disorders, were present in 83.9% of the population. Emphysema/bronchitis/chronic obstructive pulmonary disease (7%), stroke (6.8%). ³ Among older adults with emergency illnesses, the majority (80%) had an urgent severity, followed by non-urgent (10%-15%), and emergent (5%). Additionally, it was shown that some older adults return to the emergency room for repeated care after being discharged from their homes.^4,5

It is evident that the majority of older adults who visit the emergency room do so to receive treatment for comorbidities or symptoms of chronic illnesses. Some older adults return to the emergency room for repeated treatment, and the severity is at the urgent level.

6.3% and 8.4% of older adults in other countries were readmitted to the emergency room within 30 days, according to research. ⁶ Age ≥60 years, ESI triage level 2, ED length of stay ≥4 h, temperature ≥37.5°C, and 60 > pulse rate ≥100 bpm were the most significant and independent predictors of ED revisit within 48 h of release. ⁷ More serious illnesses are among the consequences of older adults’ repeated trips to emergency rooms. a worsening of a chronic condition and an increase in its complications. Over 80% of older adults are hospitalized as a result of this. ⁸ Families and individuals in their older years Poor mental health and rising treatment expenses are issues.^9,10 Compared to service recipients of other ages, older adults with emergency diseases are more likely to be admitted. ¹¹ And the provision of emergency medical services by the majority of personnel. Possibility and capacity to evaluate older adults’ complaints in urgent circumstances Still not able to be accurately assessed. ¹² Regarding the optimization of care for elderly patients in critical condition. Hospitalists and intensivists may find it easier to concentrate on the acute nature of ICU and post-ICU care while attending to the special requirements of older persons if geriatricians, who are specialists in frailty, cognitive impairment, and the treatment of older adults, are involved. ¹³ One province ranks fourth in the country in terms of the proportion of older adults, with 325 927 individuals aged 60 years and older, accounting for 18.16% of the total population. ¹⁴ As the population of older adults continues to grow, so does the prevalence of emergency illnesses among this demographic. It has an impact on how funds, personnel, supplies, and machinery are distributed. ¹⁵ And has an impact on patients’ and families’ physical, emotional, and socioeconomic well-being.

However, there is a lack of research on the frequency of emergency department (ED) visits and associated factors among older adults in this specific geographic area. As a result, the research team is interested in examining the circumstances and elements pertaining to older adults as well as the structure of health care. both at the level of primary care and the emergency room. To serve as a reference for future research aimed at lowering the frequency of ER visits among older adults

Methods

This study was conducted and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines. ¹⁶

Study Design

This study utilized a descriptive research design to examine the rates of readmission among Older Adults patients with emergency illnesses at the emergency department (ED) within 60 days of their initial visit. The research involved a follow-up period of 60 days for the patients. The 60-day threshold was selected to capture both short-term and intermediate-term re-attendance patterns, allowing adequate time for post-discharge complications to emerge. This period has been used in previous studies focusing on older adults with chronic conditions (Topaz, 2015), and aligns with hospital follow-up protocols in our setting. ²

Samples/participants

A total of 740 participants were selected through random sampling using a multi-stage method. This sample comprised 400 older adults patients who received treatment in the emergency departments of general and community hospitals. Additionally, the study included 320 healthcare professionals, including registered nurses working in emergency care and primary care providers from sub-district health promotion hospitals. Furthermore, 20 individuals were involved from emergency department leadership, sub-district hospital directors, and public health representatives from local administrative organizations. The sampling process is illustrated in Figure 1. To determine the factors linked to readmission in older persons, researchers will employ statistical analysis and group analyses.

Figure 1.

The CONSORT flow diagram of this study.

Hospital Classification refers to the categorization of hospitals based on their capacity and the referral system under the Service Plan framework of the Ministry of Public Health. The classification includes:

1. Regional Hospital (Advance: A) with a capacity over 500 beds

2. Large General Hospital (Standard: S) with a capacity of 200 to 500 beds

3. Small General Hospital (M1) with a capacity of 120 to 200 beds

4. Community Referral Hospital (M2) with a capacity of at least 120 beds

5. Large Community Hospital (F1) with a capacity of 60 to 120 beds

6. Medium Community Hospital (F2) with a capacity of 30 to 90 beds

7. Small Community Hospital (F3) with a capacity of 10 beds

Interventions

The conceptual framework for this study, which aims to determine the factors impacting older adults’ recurrent ED visits, is divided into 3 levels: the individual level, social level, and the community level. Developing health systems will benefit from this as it will minimize and lessen the effect of older adults’ repeated ER visits is illustrated in Figure 2.

Figure 2.

The conceptual framework of this study.

Instruments

The authors produced the questionnaire items, which include the Data Recording Form and the Repeat Visit Recording Form.

Data Recording Form: essential patient data, including as demographics, medical history, the severity of the illness, ED visits, hospitalization records, discharge information, transportation methods, referrals, and follow-up treatment plans, are recorded on the OPD Card, a data recording form from medical records.

Repeat Visit Recording Form: the recording form records the date, time, symptoms, severity level, and type of discharge for senior patients who return to the emergency room during a period of 60 days.

Data Collection

Healthcare professionals were invited via official hospital email systems and LINE groups. Surveys were administered through Google Forms with a secure link. Informed consent was obtained electronically prior to participation. And data was gathered by the researcher and assistance, online and interview methods were used to administer the questionnaires between July 2023 and August 2024. Details of the questionnaire used for data collection are provided in Appendix 1.

Data Analysis

The SPSS statistical program for Windows (Version 20.0) was used to examine the data. Demographic data is analyzed in this study using descriptive statistics. The association between characteristics influencing repeat treatments among older adults who visited the emergency room was examined using multiple logistic regression. A P-value of less than .05 was established as the threshold for statistical significance. To understand the qualitative data, content analysis was done.

Ethical Considerations

Ethical approval for the study was obtained from the institutional Human Research Ethics Committee on March 27, 2023. By explicitly describing the study’s goals, the procedures used to obtain the data, and the anticipated advantages for the participants and their families, the researcher made sure that the rights of the participants were protected. To guarantee that participants were fully informed before giving formal informed consent, thorough descriptions of the study were given orally and through information sheets. Participants’ privacy and confidentiality were rigorously protected during the whole investigation.

Results

Situation of Emergency Illness at the Emergency Department for the Older Adults

Table 1 presents the demographic and clinical characteristics of the participants. Fifty-two percent of them are female. The majority (28.5%) are between the ages of 65 and 69. Their co-morbidities are 71.0%. High blood pressure is one of the top 3 most prevalent illnesses. 43.2 Cardio vascular disease accounts for 12.8% and diabetes for 28.5%. Patients with non-severe emergencies (green) make up 16.8% of older adults with emergency illnesses, whereas over half (61.2%) have an emergency severity level (yellow). Pain is the most prevalent category of emergency illnesses. abdomen Distension and pain in the abdomen: 19.2%. Fatigue and exhaustion came next (19.0%), followed by fever (16.2%). Thirty percent of older adults had previously been hospitalized, and 30% had previously received emergency department treatment.

Table 1.

Factors Influencing Repeat Visits to the Emergency Department Among Older Adults Patients.

Factors	B	S.E.	df	P-value	Exp (β)	95% CI for Exp (β)
						Lower	Upper
Patient factors
1. Previous hospitalization in the last year (ever admitted; ever admitted)	0.677	0.276	1	.014*	1.968	1.146	3.378
2. Previous emergency department visits in the last year (ever visit ED)	1.367	0.317	1	.000*	3.923	2.106	7.306
Healthcare system and social support factors
1. Hospital level
F3 (reference variables)
F2	0.698	0.284	1	.014*	2.010	1.151	3.510
F1	−0.946	0.585	1	.106	.388	.123	1.223
M2	1.985	0.357	1	.000*	7.276	3.617	14.636
2. Consultation with specialists (after ED discharge; F/U)	0.821	0.266	1	.002*	2.273	1.351	3.826
Constant	−2.623	0.334	1	.000	.073

*P < .05.

Situation of Repeated Visits to the Emergency Department for Older Adults People With Emergency Illnesses

Return to the emergency room within 60 days for older adults. There were 140 older adults with urgent diseases who visited the emergency room for follow-up care within 60 days. The greatest number of repeat treatments was 3 in a 60-day period, and they accounted for 35.0% of all older adults with emergency diseases. Of all older adults who had emergency illnesses, the majority (15.8%) came for repeat treatment once, and the next most (12.8%) came for repeat treatment twice. Additional data supporting the analysis are presented in Appendix 2.

Repeat Visits for Older Adults People to the Emergency Department Within 60 Days According to Health Status

Out of 400 older adult patients, 140 (35%) revisited the emergency department (ED) within 60 days after discharge. Re-attendance was more common among male patients (38.5%) compared to female patients (31.7%), particularly among those presenting with emergency-related conditions. Older adults with co-morbidities who were 60 to 64 years old (43.2%), followed by those 65 to 69 years old (41.2%), were the age group that sought repeat therapy. Compared to older adults without co-morbidities, more persons seek repeat treatment. Chronic obstructive pulmonary disease, renal disease, gout, and asthma are the chronic conditions that require the most follow-up visits for treatment. People in their older years who have emergency illnesses with a yellow emergency severity rating come in for follow-up care. highest (39.6%), followed by the severity degree of emergency patients (pink; 30.4%). The most crucial.

Factors Affecting Repeated Visits to the Emergency Department for Older Adults People With Emergency Illnesses

Factors Affecting Repeat Treatment at the Emergency Department for the Older Adults

Including history of being hospitalized in 1 year (P-value .026), history of being treated at the emergency department in 1 year (P-value .000), level of the hospital, level F1 (P-value .000), level M2 (P-value .030).

Risk factors influencing repeated visits to the emergency department for the Older Adults were found to be Patient factors Older Adults people with a history of ever visiting the ED in 1 year increased by 1 unit and had a 3.9 times higher risk of repeat visits to the emergency department (Exp (β) = 3.923). And the Older Adults with a history of having been hospitalized in 1 year (Ever Admitted), increasing by 1 unit, had a 1.9 times increased risk of repeat admission to the emergency department (Exp (β) = 1.968).

Factors in the health service system. It was found that Older Adults people with emergency illnesses who have appointments to receive continuous treatment or see a specialist doctor (F/U) after being discharged from the emergency department increased by 1 unit, having an increased risk of seeking treatment. Repeat visits to the emergency department increased 2.2 times (Exp (β) = 2.273). And the Older Adults who come for treatment at the emergency department of a level F2 hospital have a risk of repeat treatment at the emergency department at twice that of a level F3 hospital (Exp (β) = 2.010). And the Older Adults who come for treatment at the department Emergencies at level M2 hospitals have a risk of repeat treatment at the emergency department 7 times that of level F3 hospitals (Exp (β) = 7.276).

Discussion

Over 61% of older adults with emergency illnesses were classified as urgent. Global studies confirm most older emergency cases are urgent, with 10% to 15% non-urgent and 5% emergent. Return visits often result from polypharmacy, mobility issues, or unmet care needs. Continuous geriatric evaluations and better discharge planning may reduce revisits. ¹⁷

The majority of Older Adults patients (79.2%) arrived at the ED independently, with nearly 100% not being referred to community health promotion hospitals for continued primary care. This finding is consistent with previous research (2021), ¹⁸ which reported that 80.1% of Older Adults patients traveled to the ED either by themselves or with relatives. Many Older Adults patients believed that ambulances were intended only for accident victims or feared potential costs, leading them to think their conditions were not serious enough to justify using ambulance services. In emergencies, they often preferred to get to the ED as quickly as possible on their own, believing ambulances should be reserved for more critical cases. ¹⁹

The resources to offer pre-hospital treatment, on the other hand, are available in nations with well-established EMS systems, facilitating faster access to care. In many settings, the majority of patients arrive at the emergency department (ED) independently rather than via emergency medical services (EMS), as the ability of first responders to provide timely assistance is often hindered by limited resources and staffing shortages. One hundred and forty (35.0%) of the older adult patients who sought emergency care went back to the ED within 60 days, which is a far greater proportion than in industrialized nations. Just 15.88% of older adults with chronic diseases returned to the emergency department after 60 days, according to a prior study conducted in a national context, patients with comorbidities are more likely to return to the emergency department than those without, particularly in the context of an aging population. The most prevalent condition among those returning was chronic obstructive pulmonary disease (COPD), which is in line with previous research (2020) findings that 61.9% of older adults with exacerbations of chronic lung conditions returned to the emergency department within 60 days. ¹⁸

Moreover, Older Adults patients with a history of prior visits to the ED within 1 year had a 3.9-fold increase in the risk of returning for emergency treatment (Exp (β) = 3.923). Those with a history of hospital admissions in the past year had a 1.9-fold increased risk (Exp (β) = 1.968). This trend was similarly observed in studies from Canada and Australia, which reported that Older Adults patients with previous emergency visits had an increased risk of returning within 12 months (OR 1.5 [95% CI: 1.4-1.7]; OR 2.45 [95% CI: 1.9-3.55]).^20,21 Additionally, a U.S. study found that Older Adults patients with a history of hospital admissions (OR 2.93 [95% CI: 2.71-3.18]) and those attending outpatient clinics more than 12 times a year (OR 2.66 [95% CI: 1.92-3.69]) were at an increased risk for repeat visits to the ED. ²²

In terms of health service and social support factors, Older Adults patients who had follow-up appointments with specialists after ED discharge exhibited a 2.2-fold increased risk of returning (Exp (β) = 2.273). The study found that 40.8% of Older Adults patients returning for emergency care had comorbidities, with hypertension, diabetes, cardiovascular diseases, and kidney disease being the most common. ²³ These conditions often require specialist management in larger hospitals. However, when patients fail to adhere to treatment protocols, they are at higher risk of complications, which can lead to emergency health crises. ²⁴

The study also revealed that patients treated at larger hospitals with specialized physicians and more resources had a higher risk of returning for emergency care than those treated at smaller facilities. ²⁵ Older Adults patients treated at level F2 hospitals (30-90 beds) faced twice the risk of returning to the ED compared to those treated at level F3 hospitals (10 beds; Exp (β) = 2.010). Patients treated at level M2 hospitals (120 beds or more) had a sevenfold increased risk of returning to the ED compared to those treated at level F3 hospitals (Exp (β) = 7.276). ²⁶

Despite these conclusions, research from throughout the world has shown that discharge education greatly increases the readiness of older adults and their caregivers for at-home self-care. Only 25% to 40% of older adult patients and their families in this study, however, received adequate discharge education from the emergency department. ²⁷

Limitations and Recommendations

Although the study’s conclusions are not very generalizable, they might nonetheless apply to groups in comparable circumstances. It is advised that future studies concentrate on creating a model or strategy to stop or lessen older adults’ recurrent ER visits. Research should also look at working with interdisciplinary teams, organizing healthcare services at the primary, secondary, and tertiary levels, and putting home-based continuous care into practice. Creating a discharge plan for older adults with emergency illnesses, both from the ED and inpatient wards, is also crucial in order to better prepare them and their families for at-home self-care and, eventually, to avoid or minimize repeat ED visits

Conclusion

The study showed that older adults with acute illnesses frequently had comorbidities. Over 50% of these individuals are categorized as urgently serious. Notably, referrals to health-promoting hospitals for ongoing primary care are frequently lacking for patients who return to the emergency room for recurrent treatment. Those who have already received therapy are more likely to return. Furthermore, institution level has a big influence on these results; larger hospitals with more resources and specialist geriatric doctors are more likely to have repeat visits than smaller ones. Better discharge planning, increased accessibility to emergency medical services, and improved.

Appendix 1

Data Recording Form

This form was used to collect demographic and clinical information from older adult patients. It included the following sections:

• 1. Demographic Information

• ● Age………………………………………………………..

• ● Gender………………………………………………………..

• ● Marital status………………………………………………………..

• ● Living arrangement………………………………………………………..

• ● Education level………………………………………………………..

• ● Health insurance type………………………………………………………..

• 2. Medical History

• ● Chronic conditions (eg, hypertension, diabetes, COPD)………………………………………………………..

  • (.) Diabetes mellitus
  • (.) Hypertension
  • (.) Chronic Obstructive Pulmonary Disease (COPD)
  • (.) Cardiovascular Disease (CVD)
  • (.) Other: _____________

• ● Number of medications………………………………………………………..

• ● History of hospital admissions in the past 6 months………………………………………………………..

• 3. ED Visit Information

• ● Date and time of ED visit………………………………………………………..

• ● Triage level………………………………………………………..

• ● Presenting symptoms………………………………………………………..

• ● Diagnosis at discharge………………………………………………………..

• ● Length of ED stay………………………………………………………..

• 4. Discharge Information

• ● Discharge plan………………………………………………………..

• ● Follow-up appointments arranged………………………………………………………..

• ● Patient or caregiver understanding of discharge instructions………………………………………………………..

Appendix 2

Repeat Visit Recording Form

This form was designed to track and document any emergency department revisit within 60 days of the initial visit. It included:

• 1. Patient Identification Code

• 2. Date of Repeat ED Visit

• 3. Reason for Return

• ● Worsening of existing condition………………………………………………………..

• ● New symptoms………………………………………………………..

• ● Complications related to previous diagnosis………………………………………………………..

• ● Medication-related issues………………………………………………………..

• 4. Care Received

• ● Investigations performed………………………………………………………..

• ● Treatments provided………………………………………………………..

• ● Referral or admission after revisit………………………………………………………..

• 5. Patient Outcome

• ● Discharged………………………………………………………..

• ● Re-admitted………………………………………………………..

• ● Referred for specialist follow-up………………………………………………………..