A confession: I’m a data junkie. I don’t generally collect
data (though I have carried out a few empirical studies) and I don’t analyze data
statistically. But I am fascinated by descriptive data, which often
provide remarkable insights into how
things were or how things are.
When I was working on my latest book (Old and Sick in America will come out in
October), and I wanted to know what nursing homes were like on the eve of the
introduction of Medicare, I consulted the report, “Characteristics of Residents
in Institutions for Aged or Chronically Ill: 1963,” put out by the US DHEW (as
the Department of Health and Human Services was called then). I learned there
were just over half a million people living in 16,370 nursing homes (just about
the same number of nursing homes we have today) and that they stayed there, on
average for 3 years.
When I wanted to know what hospitals were like in the
1960s, I read “Trends in Hospital Utilization: US 1965-1986” and found that
circulatory disease, which has been the number one reason for hospitalization
from the 1980s to the present, was only number 6 in 1965. Over the period from
1970 to 1986, the number of catheterizations done each year in people aged 65
and older would soar from 8,000 (or 3.8/10,000 people) to 275,000 (or
85.8/10,000) and that CABG (coronary artery bypass surgery) would likewise jump
from 0 to 125,000 (or 42.9/10,000). So periodically, I check whether the
National Center for Health Statistics has released any “Data Briefs” about
older people. This past February, the agency published “Emergency Department Visits for Injury and Illness Among Adults Aged 65 and Over, US 2012-2013.” It is
a compelling reminder that the emergency department is a key source of health
care for older people.
Focusing exclusively on illness (as opposed to accidents), the report finds that the elderly go to the emergency room often and the older they get, the more
often they go. Each year, 29 percent of people aged 65-74 have at least one
emergency visit, as do 42 percent of those aged 75-84, and 57 percent of those
aged 85 and up. About a third of these older patients arrive in the emergency
room by ambulance—highlighting the role of ambulances as another locus of
health care for this population.
These numbers don’t tell us what actually happens to older
people when they reach the ER, but other data give a few clues. In the ER, the
elderly are very likely to have some kind of imaging procedure (63 percent do),
with about half of those getting a plain X-ray and a quarter getting a CT scan.
And fully 32 percent of those presenting to the emergency department with an
illness are admitted to the hospital; 5 percent to a critical care unit. There’s
much that is left out if we focus only on descriptive statistics: we don’t know
whether these patients typically have a friend or family member with them; we
don’t know if anyone asks about their home situation; we are in the dark about
whether anyone addresses their goals of care or checks if they can walk or
determines their mental status. But the numbers are a place to start.
What is abundantly clear is that with 15.5 million visits to
the emergency department by older people every year, it’s high time we pay more
attention to what actually goes on there. We have the opportunity to figure our
whether the hospital is the right place to take care of whatever the problem is
and, if not, how to shore up the home environment to make it a viable
alternative. To answer these questions, we need to make certain that older
patients routinely undergo a brief assessment of both their cognitive and
physical functioning. We need to involve a family member if support will be
needed at home. I would bet that if we did all this, we’d make far more headway
in avoiding hospitalization and decreasing the rate of readmission than many of
the elaborate transitional care programs operating today.
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