The emergency department (ED) acts as a bridge between the community and hospital, where people are referred by their primary care physicians (PCPs) or by themselves, and plays a crucial role in regulating hospital admissions (1). In the healthcare system, the ED is vital in supporting primary care by caring for patients outside of office hours or performing advanced diagnostic investigations (1). In the recent years, there has been a surge of ED visits (2, 3), as seen in the United States where the number of visits per 1000 people have increased from 369 to 458 visits between 1995 to 2016 (4). Similarly in Singapore, the number of ED visits have risen by 250,000 from 2007 to 2013 (5). Adults aged 75 years and above had the second highest visit rate, of 52 visits per 100 people, after infants younger than one year old (6). The number of older persons, aged 65 years and above, is expected to rise (7), so is the frequency of ED utilisation by this population sub-group (4).
Older adults contribute a disproportionate number of visits to the ED (8, 9) and tend to require more extensive workup, therefore spending a greater amount of time in the ED (4). Furthermore, there is higher resource expenditure among this population in the form of advanced investigations such as computed tomography and magnetic resonance imaging (2). Compared to their younger counterparts, they are at higher risk of hospitalisation as well as adverse events when they visit the ED (10). In the United States, expenses incurred from inpatient care accounts for 31% of national healthcare spending (1). In addition, they have an increased susceptibility to hospital acquired pneumonia (11). Older adults who were discharged from the ED had a reduction in their mobility within the community, which may not improve within a year from discharge (12).
Generally, older adults have multiple comorbidities and complex medical issues that may require care beyond the PCP level (5). In a systematic review done by McCusker (2003) adapting Andersen’s Behavioural model to study the determinants of ED utilisation (13), need or illness factors were shown to be a significant determinant across many studies. This signifies that older adults truly require emergent care and may be too acutely ill to await an appointment at the PCP. In certain situations, the process of deterioration could have been deterred with regular follow-up care with PCPs (14). Moreover, McCusker found that predisposing and enabling factors that increase use of PCP will lead to a decrease in ED utilisation (13). Indeed, the presence of barriers to primary care was identified as one of the reasons why older adults turn to the ED in desperation to resolve their issues. In fact, some were told by the PCP staff to visit the ED if they felt it was urgent (15). Even though the illness factor was the predominant individual-level determinant in McCusker’s study, there exists a multitude of factors that influence the utilisation of ED that should be discussed as well. This is visualised through the model proposed by Andersen and Newman (Fig. 1), where healthcare utilisation is determined by societal or individual factors.
Individual determinants include predisposing, enabling and illness factors. Predisposing factors are patient sociodemographic characteristics that can incline or deter a patient from utilising healthcare. Enabling factors encompass the influence of family and community, with examples including marital status, living conditions and geographical accessibility to PCPs or EDs. Need or illness factors can be divided into perceived (subjective) need or evaluated (objective) need (13, 16). Societal determinants include technology and norms. Technology will help promote the efficacy of physicians providing care within the healthcare system, which can influence the decision of the population to seek medical care (17). An example of this would be the availability of X-rays and blood investigations at the ED which may not be available at the PCP level (18). Societal norms arise from governmental policies as well as societal values and beliefs (17). For instance, the stigma associated with mental health issues impedes help-seeking behaviour among people who need them and potentially deters them from utilising healthcare (19). Health insurance policies and medical subsidies by the government play a key role in a person’s decision to utilise healthcare resources (17), as demonstrated in Anderson’s study where healthcare utilisation was lower among people without insurance coverage (20).
The stress on the ED needs to be addressed to avoid jeopardising the quality of care provided and slow the surge in healthcare expenditure (3). The ill effects on older adults outlined above with regards to ED visitation emphasises the need to investigate the determinants of ED utilisation. With identification of these factors, we may be able to mitigate the number of visits to the ED by the older adult population through primary, secondary and tertiary prevention. Hence, in this paper, we outline the protocol for a systematic review of the determinants of ED utilisation among older persons (aged 65 years and above), using the framework proposed by Andersen and Newman as shown in Fig. 1.
In addition to Andersen and Newman’s model, other frameworks have been used to explain health services utilization. These include the Health Belief Model (21, 22), Social Determinants of Health (23) as well as Big Five personality traits (24, 25). Lutz 2018 devised a framework to understand ED utilisation by describing the factors that influence the decision of visiting the ED or primary care (26). In addition, He et. al proposed a modified Andersen and Newman’s model to visualise ED utilisation (27). By incorporating concepts of all the models utilised in our review, we hope to develop a more holistic approach of conceptualizing the factors that influence the decision of older adults to visit the ED.
Our protocol was developed in accordance with the standards of Campbell Collaboration guidelines for systematic reviews (28), with reference to the Cochrane Handbook for Systematic Review of Interventions (29). This protocol is registered with PROSPERO’s International Prospective Register of Systematic Reviews but pending confirmation.