Abstract
Objectives
To determine whether providing physical therapy (PT) services in the emergency department (ED) improves outcomes for older adults who fall.
Design
We used Medicare claims data to examine differences in recurrent fall-related ED revisit rates of older adults who presented to the ED for a ground-level fall and whether they received PT services in the ED. Our logistic regression model controlled for age, sex, Medicaid eligibility, acute injury, and certain known chronic comorbidities associated with risk of falling.
Setting
We analyzed national 2012–13 Medicare claims data for individuals aged 65 and older.
Participants
This was a claims-based analysis. We defined an index visit as any ED claim that included an International Classification of Diseases, Ninth Revision, Clinical Modification E-Code indicating a ground-level fall. Visits resulting in admission were excluded, as were claims associated with an individual who died during follow-up; 17,975 of the 560,277 claims for eligible outpatient index visits included revenue center codes for PT services.
Measurements
We calculated the proportion of index visits associated with a fall-related ED revisit within 30 and 60 days and assessed differences in these proportions between individuals who did and did not receive PT services in the ED.
Results
Receiving PT services in the ED during an index visit for a ground-level fall was associated with a significantly lower likelihood of a fall-related ED revisit within 30 days (odds ratio (OR)=0.655, p<.001) and 60 days (OR=0.684, p<.001).
Conclusion
Expanding PT services in the ED may reduce future fall-related ED use of older adults. Additional analyses could assess characteristics of individuals receiving PT in the ED and follow-up PT use after discharge.
Falls are the leading cause of injury-related morbidity and mortality in Americans aged 65 and older1, resulting in $31.9 billion in estimated direct medical costs to Medicare in 20152. [Correction added on October 2, 2018, after first online publication: In the previous sentence, “injury-related” was added.] In 2014, approximately 2.8 million older adults visited the emergency department (ED) for a fall-related injury1, and an analysis of the National Hospital Ambulatory Medical Care Survey determined that the ED visit rate for falls of older adults has grown over time, from 60.4 per 1,000 older adults in 2003 to 68.8 per 1,000 older adults in 20103. Older adults presenting to the ED for a fall are at high risk of ED revisits and mortality, with some estimates indicating that 25% of individuals presenting to the ED for a fall had at least 1 ED revisit and that 15% died within the following year4.
There is growing recognition that EDs could play an important role in implementing contextually appropriate fall prevention strategies targeting older adults at high risk of falls3. A range of conditions has been associated with high fall risk, including history of prior falls5, dementia and other cognitive impairment5, 6, Parkinson's disease7, depression5, 8, polypharmacy,5, 9 certain medications8, 10-12, osteoarthritis13, 14, anemia15, various heart conditions, and diabetes16. Geriatric care experts have recommended that older adults presenting to the ED be screened for fall risk and referred when appropriate17. The Geriatric Emergency Department Guidelines that relevant professional societies have released advocate for similar management18, although a chart review at an academic teaching hospital suggested that these recommendations are often not implemented19.
Given the prevalence of fall-related ED visits, there may be an opportunity to reduce fall-related revisits by offering physical therapy (PT) services to high-risk individuals in the ED, including information, diagnosis, and referral for follow-up PT after discharge. Several studies have demonstrated that older adults following a variety of PT or exercise regimens after a fall can reduce the risk of future falls20-22, but in spite of these findings, PT assessment and referral services are rare in U.S. EDs,23 and even older adults who present to the ED for a fall often do not receive appropriate assessment and referral24.
There is a need for more information on a wider scale about whether providing PT services and referrals in the ED improves outcomes. To evaluate this potential, we used nationally representative Medicare claims data to compare ED revisit rates of older adults who presented to the ED for a ground-level fall and received PT services in the ED with ED revisit rates of those who did not receive such services.