A Multilevel Analysis of the determinants of emergency care visits by the elderly in France
Introduction
Emergency departments are essential for providing a rapid and initial treatment for a large number of health problems and injuries, some of which may be life-threatening and require immediate attention. Nevertheless, they are also used as the entry point by those who do not have any other means to obtain timely and adequate health care services. The steady increase in ED visits in recent years is a source of pressure on hospitals and on the healthcare system in many countries, and raises questions on its appropriate use. In France, the number of ED visits increased by 50% between 2000 and 2015 [1], and according to surveys, two thirds of the patients chose the ED because of the geographical proximity (easy access), availability of technical equipment, opening hours, gratuity and the difficulty of finding a solution in ambulatory setting [2].
A high rate of ED visits without hospitalisation is a sign of inefficiency in the health system to provide timely and appropriate primary care services that are accessible to all [3]. In many countries, reducing ED visits has become a policy priority for improving the overall efficiency of the healthcare system [4]. Two types of admissions are targeted: visits identified as “non-urgent”, substitutable by outpatient or primary care, and visits potentially preventable by adequate and regular upstream management of risk factors and chronic health problems. A number of studies have emphasised the importance of demand-side factors, such as individual health status, socioeconomic and demographic factors. People with chronic illnesses, cognitive disorders and those suffering from multiple diseases have a greater likelihood of visiting EDs [5], [6], [7]. The youngest and the oldest population groups have higher ED utilisation rates [2]. The elderly population is often characterised by a proliferation of health problems that may be aggravated by psychological and/or social issues. Inadequate healthcare and social support for older people with complex health needs can lead to visits to emergency departments which are not necessarily the best settings for ensuring optimal provision of coordinated care [2], [5].
At the same time, the link between the individual demand variables and the need for ED utilisation is determined by the way the health system is configured [3], [4]. The financial and physical accessibility of healthcare for different populations is critical. In France, the introduction of universal health insurance (Couverture Maladie Universelle; CMU) for low-income and state medical aid for illegal residents which removed financial barriers to regular care, appear to have reduced significantly ED visits of the populations concerned [2], [8]. In England, Cecil et al. [9] showed that children aged less than 15 years old with good access to primary care (measured by waiting time for appointments), have a lower probability of visiting the ED [9]. Based on an international survey of 34 countries, excluding France, Van den Berg et al. (2015) suggest that accessibility of primary care, measured by opening hours of general practitioners (GP) and distances to a GP, is an important determinant of the ED visits [10]. In France, where the geographical distribution of the health workforce is very unequal, a wide range of policies have been put in place to strengthen primary care provision with the idea that better accessibility of primary care, especially for the high-need/high-cost elderly population could be a lever for reducing hospital use and ultimately improving system efficiency. Despite an increasing attention to ED utilisation and to primary care interventions for improving care pathways, a few studies looked at the relationship between the healthcare contexts in which patients live and ED utilisation.
This study aims to establish the determinants of ED visits in France at a territorial level with a focus on the impact of ambulatory care organisation (both primary and specialist care) for the population aged 65 years and over. Using multilevel regression models, we analyse the role of healthcare delivery at the municipal and wider department level in determining emergency care use, while simultaneously controlling for demographic, socioeconomic and health context of the municipalities in which patients live. We restrict the analysis on ED visits to those without hospitalisation in order to homogenise the patient population (cases relatively less serious or not vital) with the hypothesis that these visits could be substituted and/or avoided by appropriate/timely primary care interventions.
Section snippets
Empirical approach
We examine the rate of ED visits at the municipality area (commune) level as the smallest territorial unit which has a meaning for healthcare organisation. This is the territorial division used for monitoring primary healthcare supply in France. ED visit rates are calculated according to patients’ place of residence (rather than treatment/hospital location). The socio-economic context and average health status of the area in which patients live will have an impact on their health/emergency care
Descriptive statistics
In 12 regions of our study, on average, 9.4% of the population aged over 65 had an ED visit without hospitalisation (757,031 persons in 2013), but the rates varied significantly across municipalities (CV 48%, Table 1). The average age of the population studied was 75 years old, 55% had at least one chronic illness, and the average mortality rate was 90 per 10,000 (for all ages). The average distance to the nearest emergency department was 19 min with a standard deviation of 9.25 min.
Nearly 18%
Discussion
Visits to emergency departments have been increasing steadily in France, as in many other countries, raising issues on the accessibility, quality and efficiency of care provided in other parts of the health system. A better understanding of the factors linked to the local healthcare context is important for improving healthcare configurations to avoid unnecessary ED visits and ensure that patients receive the right care in the right structure at the right time.
By using multilevel regression
Conclusions
Emergency visits to hospitals are costly and can be unsettling experiences for patients, especially for the elderly. High rates of ED visits call into question the quality, efficiency and accessibility of health services provided in ambulatory settings. Rising numbers of ED visits create pressure on hospitals but also, by their high costs, on the sustainability of health funding.
In this paper we examined the roles of a set of population level push and pull factors affecting ED utilisation by
Conflicts of interest
Authors declare no conflict of interest.
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