We found that half of the HHC patients were aged ≥ 85 years and predominantly female. Independent predictors of ED visits were urinary catheter use and underlying comorbidities of PUD/GERD. In the univariable analysis, nasogastric tube feeding, and a history of benign prostate hypertrophy were significantly higher among patients with than among those without ED visits. Age ≥ 85 years did not predict ED visits. Stratified analyses showed that PUD/GERD and dyslipidemia were independent predictors of ED visits in female patients.
Patients with urinary catheters have more opportunities to visit the ED due to complications of urinary catheter use[13-15]. Patients with benign prostate hypertrophy are at higher risk of urinary retention and subsequent urinary catheter insertion[16]. Another possibility is that functional disabilities in HHC patients with urinary catheters may be more severe, which increases the risk of ED visits[17]. A study conducted in Canada reported that having a urinary catheter increased the risk of ED visits[15]. Another study conducted in the United Kingdom revealed that 41% of patients with urinary catheter problems were hospitalized and 49% of them received antibiotics following ED visits[13]. Most admissions were indicated for intravenous antibiotics under the impression of urinary catheter-related infections[13]. To avoid urinary catheter-related complications, the Centers for Disease Control and Prevention in the United States published the CAUTI (Catheter-Associated Urinary Tract Infections) guideline to help health care providers appropriately use urinary catheters[18].
PUD/GERD is a common problem among older people[19, 20]. Despite the advancement in treatment for PUD/GERD, the rate of peptic ulcer bleeding and morbidity remains high for elderly patients[19]. Elderly patients are prescribed NSAIDs (Non-steroidal anti-inflammatory drugs) and aspirin for pain and prevention of cardiovascular and cerebrovascular diseases, due to multiple comorbidities which increases the risk of complications, ED visits, hospitalization, and even death[19, 20].
Patients with nasogastric tubes often visit the ED due to dislodged and blocked tubes[14]. A study conducted in the United Kingdom reported that 30% of patients with nasogastric tube problems were hospitalized following ED visits, and the average cost per attendance was $1,071[14]. Cautious use of nasogastric tubes is suggested for older frail people because it does not affect the outcome and quality of life. In a study conducted in Taiwan, older patients on nasogastric tube feeding had a higher risk of pneumonia than those on assisted hand feeding (48% vs. 26%, p = 0.015)[21]. The hospitalization rate and duration in the patients on nasogastric tube feeding were not lower than for those on assisted hand feeding[21]. In addition to identifying these predictors, strategies for preventing them during ED visits, including the education of caregivers and health care providers, are also needed[14].
Interestingly, patients aged ≥ 85 years did not have higher ED visit rates than those aged< 85 years in this study. Generally, increasing age contributes to increased ED visit rates[22]. However, HHC patients and nursing home residents may not have the same medical resource use with general elders because they already have routine health care. A systemic review showed that there is no clear association between age and ED visits among nursing home residents[23].
For female patients, PUD/GERD and dyslipidemia were independent predictors of ED visits in this study; however, this result was not found for male patients. The possible reason is that older women have more PUD/GERD-associated symptoms than older men, contributing to an increased ED visit rate. A meta-analysis reported that women are 40% more likely to have GERD symptoms than men in South America and the Middle East [24]. In Taiwan, a study including 1238 participants reported that the female sex was an independent predictor of the development of GERD[25]. The odds ratio of the female sex was 1.71 with a 95% CI of 1.26−2.34 after multivariate analyses [25]. The positive association between dyslipidemia and ED visits is difficult to explain based on current evidence. A study on ED visits after bariatric surgery reported that dyslipidemia was an independent predictor[26]. However, the authors did not explain the cause. Further studies are needed to clarify this issue.
The major strength of this study is that it is the first study conducted in Asia to identify independent predictors of ED visits in HHC patients. It provides an important reference for the early prevention and recognition of at-risk patients and may help HHC providers to adjust care plans. Another benefit of the result of this study is that it provides evidence to decrease the use of urinary catheters in HHC patients. However, this study has a few limitations. First, our data were collected from a single medical center; therefore, the generalization of the result requires external validation. Second, because the sample size is small, the variables that were not statistically significant still require attention. Recruiting more HHC patients and validations in other hospitals are warranted in the future.