Background: Many older adults in the US visit the ED and are admitted to the hospital in their last month of life. It is unknown whether admission to the acute setting is associated with underlying prognosis.
Design and Participants: Cross -sectional analysis of older adults who visited one of 29 EDs participating in the “Primary Palliative Care for Emergency Medicine” (PRIM-ER) study. Medicare claims data identified 301,044 unique patients aged 66 and older having visits at one of the 29 EDs. A Gagne score was used to estimate illness severity and 6-month mortaility risk as high (>6) or low (<=6). The final sample consisted of 38,793 high risk and 262,251 low risk older adults.
Results: For the whole population (N = 301,044), the number of inpatient admissions (N=262,251) increased with age (65-75: 42%, 76-85: 48%, 86 and older: 57%). Males had more inpatient admissions than females, and non-Hispanic whites had more inpatient admissions compared to other races/ethnicities. Increasing Gagne score was associated with increasing inpatient admission (<3: 40%, 3-6: 53%, 7-9: 62%, >9: 67%). Among admitted patients, more males than females and more non-Hispanic whites than other races/ethnicities were transferred to the ICU. Higher Gagne scores were associated with higher proportion of transfers to the ICU (12% <3-6, 14% 7-9, 16% >9). Regression analysis results showed that a 10-year increase in age was associated with a 35% increased likelihood of inpatient admissions (AOR: 1.35; 95% CI, 1.30−1.40). Males were 33% more likely to be admitted than females (AOR: 1.33; 95% CI, 1.31−1.35). Patients identified as having high risk for short-term mortality were 139%(AOR: 2.39; 95%CI,2.12−2.70) more likely to be admitted. For each 1 point increase in the Gagne score, the likelihood of inpatient admission increased by 6% (AOR:1.06;95%CI,1.04−1.09). Regarding ICU transfer, a 10-year increase in age was associated with 13% increased odds of transfer (AOR:1.13;95%CI,1.06−1.21). Patients with a high risk for short term mortality were 114% more likely to be transferred (AOR:2.14;95%CI,1.93−2.36), and for each 1 point increase in the Gagne score the likelihood of ICU transfer increased by 8% (AOR:1.08;95%CI,1.06−1.09).
Commentary: In this large study of older adults, increasing age, male sex, and higher risk of short-term mortality significantly increased the odds of hospital admission and ICU transfer. Patients with a high risk of short-term mortality were over twice as likely to be admitted and to be transferred to the ICU after admission. This study was limited by only using billing data which made it difficult to determine actual treatment intensity. This also limits our insight into the patients’ treatment preferences or whether the care provided was in line with their goals. Using this data, it is not possible to determine if the measured racial/ethnic differences were due to underlying systemic healthcare bias, varying cultural and religious beliefs, or some combination thereof. Furthermore, there was no information available on other sociodemographic factors which could have played a role such as education, marital status, income, or social support. However, the use of Medicare claims data could serve as a readily available resource from which other studies could be undertaken to further identify gaps and disparities in care.
Bottom Line: Patients with a high risk of short-term-mortality often present to the hospital for admission. This highlights an important opportunity to address goals of care to prevent non-goal concordant or burdensome care.
Source: The reference for the article in AMA style Adeyemi O, Hill J, Siman N, Goldfeld KS, Cuthel AM, Grudzen CR. Acute Care Use and Prognosis in Older Adults Presenting to the Emergency Department. J Pain Symptom Manage. 2025;69(6):559-568. doi:10.1016/j.jpainsymman.2025.01.006
Acute Care Use and Prognosis presenting to ED.pdf
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