Patterns of emergency ambulance use, 2009–13: a comparison of older people living in Residential Aged Care Facilities and the Community

Patterns of emergency ambulance use, 2009–13: a comparison of older people living in... Abstract Objective to examine demand for emergency ambulances by older people. Design retrospective cohort study using secondary analysis of routinely collected clinical and administrative data from Ambulance Victoria, and population data from the Australian Bureau of Statistics and the Australian Institute of Health and Welfare. Setting Victoria, Australia. Participants people aged 65 years and over, living in Residential Aged Care Facilities (RACF) and the community, attended by emergency ambulance paramedics, 2009–13. Main outcome measures rates of emergency ambulance attendance. Results older people living in RACF experienced high rates of emergency ambulance attendance, up to four times those for age- and sex-matched people living in the community. Rates remained constant during the study period equating to a consistent, 1.45% average annual increase in absolute demand. Rates peak among the 80–84-year group where the number of attendances equates to greater than one for every RACF-dwelling person each year. Increased demand was associated with winter months, increasing age and being male. Conclusion these data provide strong evidence of high rates of emergency ambulance use by people aged 65 years and over living in RACF. These results demonstrate a clear relationship between increased rate of ambulance use among this vulnerable group of older Australians and residence, sex, age and season. Overall, absolute demand continues to increase each year adding to strain on health resources. Additional research is needed to elucidate individual characteristics, illness and health system contributors to ambulance use to inform strategies to appropriately reduce demand. residential aged care, ambulance, older people, emergency care, pre-hospital Introduction Globally, older people are found to frequently engage with emergency medical services (EMS) with high rates of emergency department (ED) presentations and unplanned hospital admissions [1–4]. EMS use by residential aged-care facility (RACF)-dwelling people may differ considerably from those living in the community [5–7]. Additionally, due to the often-complex chronic health and social needs of this population, these patients are frequently referred to emergency-care for non-urgent complaints, a potentially inappropriate use [1, 8]. Ambulance services provide a vital, emergency, point-of-care health service, but are experiencing increasing demand, leading to potential problems with timely service delivery and adequate resource allocation across health systems [2, 9]. To date, the majority of urgent-care research has focused on management of these patients within the ED, however a considerable amount of emergency assessment and intervention occurs within the pre-hospital setting, largely by ambulance services. Almost all published data regarding acute-care for RACF-patients is from hospital records and databases. This, in-hospital documentation may be an incomplete indicator of pre-hospital emergency-care, not capturing important clinical interactions including patients treated without transport to hospital. It is important to examine rates of ambulance usage by this population, to optimise service provision, to ensure appropriate use of finite health resources and to plan for future demand. In addition, understanding patterns of ambulance use allows for structured identification of potential avenues for alternate acute-care pathways. The aim of this study was to investigate rates of emergency ambulance attendance to older RACF-dwelling patients, to examine trends in demand over a 5-year period, and to compare rates with those for the community-dwelling population. Methods Study design A retrospective cohort study was conducted, using analysis of routinely collected clinical and administrative data from Ambulance Victoria (AV), and population data from the Australian Bureau of Statistics (ABS) and the Australian Institute of Health and Welfare (AIHW). This study was approved by the Monash University Human Research Ethics Committee (CF14/2705-2014001396); and by the AV Research Governance Committee (R14-012). Data sources De-identified data were provided by AV for emergency-ambulance attendance for all patients aged 65 years and over, in Victoria, Australia from 1 January 2008 to 31 December 2013. Data fields encompassed patient’s demographic characteristics including case-number, date, age, sex and scene-location [10]. Quarterly population age and sex estimates derived from the 2016 Census of Population and Housing, birth/death registration, and migration data were sourced from the ABS [11]. Data for population in RACF(2008–13) were sought from the AIHW National Aged Data Clearing House [12]. Data analysis Ambulance attendance for RACF-residents were identified if the scene-locations were recorded as ‘Nursing-home/Supported-Accommodation’ and for community-dwelling people if the scene-locations were recorded as ‘private residence’, ‘public place’, ‘recreation/sporting complex’, ‘vehicle’ and ‘workplace’. Analyses were conducted using STATA-14 (StataCorp, College Station, TX, USA). The primary outcome, rate of ambulance attendance was calculated by the number of events divided by the population of that group in the specific time period. Rates were converted to attendances per 1,000-people. Rates were calculated for RACF- and community-dwelling groups by year, age-group, sex and quarter. Multiple crews attending the same case were considered a single attendance. Results Data included 1,018,810 emergency-ambulance attendances over the 6-year period. Rate estimates could not be calculated for 2008 as data were incomplete for the first half of that year and therefore excluded from analysis. The average ambulance attendance rate for older RACF-dwelling people was greater than 770 per 1,000-people per year (Table 1). This was up to four-times higher than that of community-dwelling people, with the difference growing to 8-fold among the youngest age-group (65–69 years). The annual rate for this population was consistent over the 5-years, from 2009–13 indicating a yearly increase in absolute number of attendances (Table 1). Table 1. Rates per 1,000 population of emergency ambulance attendance for RACF- and community-dwelling population aged 64 years and over in Victoria, from 2009 to 2013 Year  RACF-dwelling population  Community-dwelling population  Number of ambulance call-outs  Rate per 1,000 population (95% confidence intervals (CI))  Number of ambulance call-outs  Rate per 1,000 population (95% CI)  2009  31,292  789 (785, 793)  138,527  200 (199, 201)  2010  31,530  777 (773, 781)  147,557  207 (206, 208)  2011  32,045  779 (775, 783)  155,758  212 (211, 212)  2012  33,062  795 (791, 799)  164,673  215 (214, 215)  2013  33,139  788 (784, 792)  167,675  211 (210, 212)  Year  RACF-dwelling population  Community-dwelling population  Number of ambulance call-outs  Rate per 1,000 population (95% confidence intervals (CI))  Number of ambulance call-outs  Rate per 1,000 population (95% CI)  2009  31,292  789 (785, 793)  138,527  200 (199, 201)  2010  31,530  777 (773, 781)  147,557  207 (206, 208)  2011  32,045  779 (775, 783)  155,758  212 (211, 212)  2012  33,062  795 (791, 799)  164,673  215 (214, 215)  2013  33,139  788 (784, 792)  167,675  211 (210, 212)  Table 1. Rates per 1,000 population of emergency ambulance attendance for RACF- and community-dwelling population aged 64 years and over in Victoria, from 2009 to 2013 Year  RACF-dwelling population  Community-dwelling population  Number of ambulance call-outs  Rate per 1,000 population (95% confidence intervals (CI))  Number of ambulance call-outs  Rate per 1,000 population (95% CI)  2009  31,292  789 (785, 793)  138,527  200 (199, 201)  2010  31,530  777 (773, 781)  147,557  207 (206, 208)  2011  32,045  779 (775, 783)  155,758  212 (211, 212)  2012  33,062  795 (791, 799)  164,673  215 (214, 215)  2013  33,139  788 (784, 792)  167,675  211 (210, 212)  Year  RACF-dwelling population  Community-dwelling population  Number of ambulance call-outs  Rate per 1,000 population (95% confidence intervals (CI))  Number of ambulance call-outs  Rate per 1,000 population (95% CI)  2009  31,292  789 (785, 793)  138,527  200 (199, 201)  2010  31,530  777 (773, 781)  147,557  207 (206, 208)  2011  32,045  779 (775, 783)  155,758  212 (211, 212)  2012  33,062  795 (791, 799)  164,673  215 (214, 215)  2013  33,139  788 (784, 792)  167,675  211 (210, 212)  Among RACF-residents there was a persistently higher rate of ambulance attendances for men than women with a rate ratio of 1.39. This is in comparison to the community-dwelling population where the rate of attendances was similar between sexes (rate ratio 1.03; Supplementary Table S2, available in Age and Ageing online). Demand peaked at over 1,000 attendances per 1,000-people among RACF-residents aged 80–84 years (Supplementary Table S3, available in Age and Ageing online), equating to at least one attendance per RACF-dwelling person of that age per-year. With increasing age, RACF-residents experienced increased attendance rates up to 80–84 years (Supplementary Table S3, available in Age and Ageing online), rates then declined slightly. In comparison, the community-dwelling group experienced a consistent increase in demand with age, across all age-groups (Supplementary Figure S2, available in Age and Ageing online). There was demonstrable variability in ambulance usage according to season with the highest rates during winter, July–September; and lower rates during summer, January–March (Figure 1). This variability in demand was far more pronounced among the RACF-population than the community-dwelling groups who experienced only slight rate fluctuations across the year (Figure 1). Figure 1. View largeDownload slide Rates per 1,000 population of ambulance attendance for 65+ year-old RACF-and community-dwelling population in Victoria by quarter and sex from 20. Figure 1. View largeDownload slide Rates per 1,000 population of ambulance attendance for 65+ year-old RACF-and community-dwelling population in Victoria by quarter and sex from 20. Discussion To our knowledge, this is the first study to describe rates of emergency-ambulance use by a highly vulnerable patient group, older people living in RACFs. It reveals whole-of-system demand, over a 5-year period for ambulance services by this sub-population and trends in rates over time. Ambulance attendance to RACF-dwelling people is up to four-times that of age- and sex-matched community-dwelling people and novel patterns in demand are described, in particular greater use by men, and during winter, with notable variation in attendance rates with age. We acknowledge some limitations. This retrospective analysis of routinely collected data relies on accurate documentation by paramedics and administrators at the time of patient interaction. In this study, demand from older RACF-dwelling people was very high, but consistent with internationally reported rates of ED-presentation and unplanned hospital admissions [5, 13]. Therefore, it is likely that these findings reflect global trends. Compared with community-dwelling people, those in RACFs experienced up to four-times greater ambulance usage. There are probable patient and health-system contributors to this disparity. Older RACF-dwelling people are likely to have poorer health, higher burden of chronic illness, frailty and cognitive impairment; all of which increase susceptibility to acute illness, falls and injury [4, 14]. Additionally, these conditions add complexity to clinical assessment, perhaps leading to a lower threshold to call an ambulance. This may be exacerbated by RACF-staffing patterns where personal-care attendants predominate alongside limited numbers of registered nurses and sessional doctors’ visits [4, 15]. Physical and cognitive disabilities may also increase the logistical complexity of medical investigations such as x-rays. Some mobile services attend RACFs, but elsewhere these involve transport to a secondary site, necessitating additional equipment, vehicles and staff-escorts. This may lead RACF-staff to call an ambulance to facilitate assessment. Access to community services may also be limited to certain times and days. Ambulance use by RACF residents is relatively consistent across all days of the week with evening peaks in demand [16]. This may fall outside standard hours for General Practitioners and out-reach services, leading to alternate use of ambulances. Our results demonstrate a seasonal effect with peak rates in winter and lowest demand in summer. This fluctuation was more pronounced for RACF-dwelling compared community-dwelling people. Older RACF populations may be more vulnerable to infectious disease, have higher rates of resistant organisms, and variable prevalence of immunisations [7, 17, 18]. Seasonal variation may therefore reflect heightened susceptibility to illnesses such as influenza, or less health reserve leading to greater disease severity, necessitating emergency care. Additionally, with close-living quarters or limited staffing resources calling an ambulance may provide an easier alternative to ongoing care within the RACF. Our study demonstrates a clear difference in ambulance attendance rates between older women and men living in RACF, but not the community. Similar differences have been suggested previously [2, 4, 19] though the cause remains unclear. It is possible that ambulances are being either under-utilised by one sex or over-utilised by the other. With higher rates of cognitive impairment, impaired mobility and institutionalised behaviour, older RACF-dwelling people are more dependent on staff to recognise an acute health deterioration and call an ambulance. The disparity suggests gender bias in the perception of, and response to, acute injury or illness in older RACF-patients by care- and/or health-workers. Factors contributing to this may include differences in clinical signs, behaviour patterns and coping strategies between women and men, which may influence interactions between patients and healthcare professionals. Previous studies have reported significant sex-differences in experience of illness, symptom-reporting and healthcare seeking behaviour [20, 21]. Whilst important, these factors are insufficient to adequately explain this difference in demand. The possibility that the threshold to seek emergency-care for men is lower than it is for women cannot be discounted. Conclusion This study provides robust evidence of very high rates of emergency-ambulance use by older RACF-dwelling people. Rates remained constant over the study period associated with a yearly increase in absolute ambulance use, a trend that is expected to persist. On a macro-level, these results provide clear evidence of associations between ambulance attendance and place of residence, sex, age and season, essential for effective health-service planning. Older RACF-dwelling people are a unique and growing patient group within the emergency healthcare system. Further research is needed to better describe clinical patterns of acute-illness and need for medical intervention to elucidate optimal modes of emergency-care for these vulnerable patients. This will also be beneficial in addressing gaps in training of RACF-staff to respond to acute health concerns, and in development of institutional guidelines for both RACFs and EMS. Additional studies are needed to evaluate individual healthcare interventions, including advanced care directives, on emergency ambulance demand. Key points Older RACF dwelling people are highly vulnerable patients. Their emergency care may be complex and have unintended negative consequences for individual patients and health system. RACF dwelling older patients have a very high rate of ambulance use. Rate of ambulance use is greater than that of community-dwelling people and varies according to age, sex and time of year. Supplementary data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Conflict of interest K. Smith is Director of the Centre for Research and Evaluation at Ambulance Victoria. Funding R. Dwyer is supported by a Monash University Faculty Postgraduate Research Scholarship. References 1 Carter MW, Datti B, Winters JM. ED visits by older adults for ambulatory care-sensitive and supply-sensitive conditions. Am J Emerg Med  2006; 24: 428– 34. Google Scholar CrossRef Search ADS PubMed  2 Lowthian J, Jolley D, Curtis A et al.  . The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995–2015. MJA  2011; 194: 574– 8. Google Scholar PubMed  3 Arendts G, Dickson C, Howard K, Quine S. Transfer from residential aged care to emergency departments: an analysis of patient outcomes. Intern Med J  2012; 42: 75– 82. Google Scholar CrossRef Search ADS PubMed  4 Dwyer R, Stoelwinder J, Gabbe B, Lowthian J. Unplanned transfer to emergency departments for frail elderly residents of aged care facilities: a review of patient and organizational factors. J Am Med Dir Assoc  2015; 16: 551– 62. Google Scholar CrossRef Search ADS PubMed  5 Wang HE, Shah MN, Allman RM, Kilgore M. Emergency department visits by nursing home residents in the United States. J Am Geriatr Soc  2011; 59: 1864– 72. Google Scholar CrossRef Search ADS PubMed  6 Street M, Marriott JR, Livingston PM. Emergency department access targets and the older patient: a retrospective cohort study of emergency department presentations by people living in residential aged care facilities. Australas Emerg Nurs J  2012; 15: 211– 8. Google Scholar CrossRef Search ADS PubMed  7 Dwyer R, Gabbe B, Stoelwinder JU, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing  2014; 43: 759– 66. Google Scholar CrossRef Search ADS PubMed  8 Carter L, Skinner J, Robinson S. Patients from care homes who attend the emergency department: could they be managed differently. Emerg Med J  2009; 26: 259– 62. Google Scholar CrossRef Search ADS PubMed  9 Lowthian J, Cameron P, Stoelwinder JU et al.  . Increasing utilisation of emergency ambulances. Aust Health Rev  2011; 35: 63– 9. Google Scholar CrossRef Search ADS PubMed  10 Cox S, Martin R, Somaia P, Smith K. The development of a data-matching algorithm to define the ‘case patient’. Aust Health Rev  2013; 37: 54– 9. Google Scholar CrossRef Search ADS PubMed  11 Australian Bureau of Statistics. Quarterly Population Estimates (ERP), by State/Territory, Sex and Age 2017 [Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3101.0Main+Features1Dec2016?OpenDocument. 12 Number of residents aged 65 and over in permanent residential aged care, by age, sex and remoteness, Victoria, September quarter 2007–December quarter 2013. AIHW Clearinghouse. 13 Vossius CE, Ydstebo AE, Testad I, Luras H. Referrals from nursing home to hospital: reasons, appropriateness and costs. Scand J Public Health  2013; 41: 366– 73. Google Scholar CrossRef Search ADS PubMed  14 Spector WD, Limcangco R, Williams C, Rhodes W, Hurd D. Potentially avoidable hospitalizations for elderly long-stay residents in nursing homes. Med Care  2013; 51: 673– 81. Google Scholar CrossRef Search ADS PubMed  15 Intrator O, Zinn J, Mor V. Nursing home characteristics and potentially preventable hospitalizations of long-stay residents. J Am Geriatr Soc  2004; 52: 1730– 6. Google Scholar CrossRef Search ADS PubMed  16 Cantwell K, Morgans A, Smith K, Livingston M, Dietze P. Differences in emergency ambulance demand between older adults living in residential aged care facilities and those living in the community in Melbourne, Australia. Australas J Ageing  2017; 36: 212– 21. Google Scholar CrossRef Search ADS PubMed  17 Carroll NV, Delafuente JC, McClure KL, Weakley DF, Khan ZM, Cox FM. Economic burden of influenza-like illness in long-term-care facilities. Am J Health Syst Pharm  2001; 58: 1133– 8. Google Scholar PubMed  18 Lautenbach E, Fishman NO, Bilker WB et al.  . Risk factors for fluoroquinolone resistance in nosocomial Escherichia coli and Klebsiella pneumoniae infections. Arch Intern Med  2002; 162: 2469– 77. Google Scholar CrossRef Search ADS PubMed  19 Graverholt B, Riise T, Jamtvedt G, Ranhoff AH, Kruger K, Nortvedt MW. Acute hospital admissions among nursing home residents: a population-based observational study. BMC Health Serv Res  2011; 11: 126. Google Scholar CrossRef Search ADS PubMed  20 Macintyre S, Hunt K, Sweeting H. Gender differences in health: are things really as simple as they seem? Soc Sci Med  1996; 42: 617– 24. Google Scholar CrossRef Search ADS PubMed  21 Canto J, Goldberg RJ, Hand M et al.  . Symptom presentation of women with acute coronary syndromes. Arch Intern Med  2007; 167: 2405– 13. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Age and Ageing Oxford University Press

Patterns of emergency ambulance use, 2009–13: a comparison of older people living in Residential Aged Care Facilities and the Community

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© The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com
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0002-0729
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Abstract

Abstract Objective to examine demand for emergency ambulances by older people. Design retrospective cohort study using secondary analysis of routinely collected clinical and administrative data from Ambulance Victoria, and population data from the Australian Bureau of Statistics and the Australian Institute of Health and Welfare. Setting Victoria, Australia. Participants people aged 65 years and over, living in Residential Aged Care Facilities (RACF) and the community, attended by emergency ambulance paramedics, 2009–13. Main outcome measures rates of emergency ambulance attendance. Results older people living in RACF experienced high rates of emergency ambulance attendance, up to four times those for age- and sex-matched people living in the community. Rates remained constant during the study period equating to a consistent, 1.45% average annual increase in absolute demand. Rates peak among the 80–84-year group where the number of attendances equates to greater than one for every RACF-dwelling person each year. Increased demand was associated with winter months, increasing age and being male. Conclusion these data provide strong evidence of high rates of emergency ambulance use by people aged 65 years and over living in RACF. These results demonstrate a clear relationship between increased rate of ambulance use among this vulnerable group of older Australians and residence, sex, age and season. Overall, absolute demand continues to increase each year adding to strain on health resources. Additional research is needed to elucidate individual characteristics, illness and health system contributors to ambulance use to inform strategies to appropriately reduce demand. residential aged care, ambulance, older people, emergency care, pre-hospital Introduction Globally, older people are found to frequently engage with emergency medical services (EMS) with high rates of emergency department (ED) presentations and unplanned hospital admissions [1–4]. EMS use by residential aged-care facility (RACF)-dwelling people may differ considerably from those living in the community [5–7]. Additionally, due to the often-complex chronic health and social needs of this population, these patients are frequently referred to emergency-care for non-urgent complaints, a potentially inappropriate use [1, 8]. Ambulance services provide a vital, emergency, point-of-care health service, but are experiencing increasing demand, leading to potential problems with timely service delivery and adequate resource allocation across health systems [2, 9]. To date, the majority of urgent-care research has focused on management of these patients within the ED, however a considerable amount of emergency assessment and intervention occurs within the pre-hospital setting, largely by ambulance services. Almost all published data regarding acute-care for RACF-patients is from hospital records and databases. This, in-hospital documentation may be an incomplete indicator of pre-hospital emergency-care, not capturing important clinical interactions including patients treated without transport to hospital. It is important to examine rates of ambulance usage by this population, to optimise service provision, to ensure appropriate use of finite health resources and to plan for future demand. In addition, understanding patterns of ambulance use allows for structured identification of potential avenues for alternate acute-care pathways. The aim of this study was to investigate rates of emergency ambulance attendance to older RACF-dwelling patients, to examine trends in demand over a 5-year period, and to compare rates with those for the community-dwelling population. Methods Study design A retrospective cohort study was conducted, using analysis of routinely collected clinical and administrative data from Ambulance Victoria (AV), and population data from the Australian Bureau of Statistics (ABS) and the Australian Institute of Health and Welfare (AIHW). This study was approved by the Monash University Human Research Ethics Committee (CF14/2705-2014001396); and by the AV Research Governance Committee (R14-012). Data sources De-identified data were provided by AV for emergency-ambulance attendance for all patients aged 65 years and over, in Victoria, Australia from 1 January 2008 to 31 December 2013. Data fields encompassed patient’s demographic characteristics including case-number, date, age, sex and scene-location [10]. Quarterly population age and sex estimates derived from the 2016 Census of Population and Housing, birth/death registration, and migration data were sourced from the ABS [11]. Data for population in RACF(2008–13) were sought from the AIHW National Aged Data Clearing House [12]. Data analysis Ambulance attendance for RACF-residents were identified if the scene-locations were recorded as ‘Nursing-home/Supported-Accommodation’ and for community-dwelling people if the scene-locations were recorded as ‘private residence’, ‘public place’, ‘recreation/sporting complex’, ‘vehicle’ and ‘workplace’. Analyses were conducted using STATA-14 (StataCorp, College Station, TX, USA). The primary outcome, rate of ambulance attendance was calculated by the number of events divided by the population of that group in the specific time period. Rates were converted to attendances per 1,000-people. Rates were calculated for RACF- and community-dwelling groups by year, age-group, sex and quarter. Multiple crews attending the same case were considered a single attendance. Results Data included 1,018,810 emergency-ambulance attendances over the 6-year period. Rate estimates could not be calculated for 2008 as data were incomplete for the first half of that year and therefore excluded from analysis. The average ambulance attendance rate for older RACF-dwelling people was greater than 770 per 1,000-people per year (Table 1). This was up to four-times higher than that of community-dwelling people, with the difference growing to 8-fold among the youngest age-group (65–69 years). The annual rate for this population was consistent over the 5-years, from 2009–13 indicating a yearly increase in absolute number of attendances (Table 1). Table 1. Rates per 1,000 population of emergency ambulance attendance for RACF- and community-dwelling population aged 64 years and over in Victoria, from 2009 to 2013 Year  RACF-dwelling population  Community-dwelling population  Number of ambulance call-outs  Rate per 1,000 population (95% confidence intervals (CI))  Number of ambulance call-outs  Rate per 1,000 population (95% CI)  2009  31,292  789 (785, 793)  138,527  200 (199, 201)  2010  31,530  777 (773, 781)  147,557  207 (206, 208)  2011  32,045  779 (775, 783)  155,758  212 (211, 212)  2012  33,062  795 (791, 799)  164,673  215 (214, 215)  2013  33,139  788 (784, 792)  167,675  211 (210, 212)  Year  RACF-dwelling population  Community-dwelling population  Number of ambulance call-outs  Rate per 1,000 population (95% confidence intervals (CI))  Number of ambulance call-outs  Rate per 1,000 population (95% CI)  2009  31,292  789 (785, 793)  138,527  200 (199, 201)  2010  31,530  777 (773, 781)  147,557  207 (206, 208)  2011  32,045  779 (775, 783)  155,758  212 (211, 212)  2012  33,062  795 (791, 799)  164,673  215 (214, 215)  2013  33,139  788 (784, 792)  167,675  211 (210, 212)  Table 1. Rates per 1,000 population of emergency ambulance attendance for RACF- and community-dwelling population aged 64 years and over in Victoria, from 2009 to 2013 Year  RACF-dwelling population  Community-dwelling population  Number of ambulance call-outs  Rate per 1,000 population (95% confidence intervals (CI))  Number of ambulance call-outs  Rate per 1,000 population (95% CI)  2009  31,292  789 (785, 793)  138,527  200 (199, 201)  2010  31,530  777 (773, 781)  147,557  207 (206, 208)  2011  32,045  779 (775, 783)  155,758  212 (211, 212)  2012  33,062  795 (791, 799)  164,673  215 (214, 215)  2013  33,139  788 (784, 792)  167,675  211 (210, 212)  Year  RACF-dwelling population  Community-dwelling population  Number of ambulance call-outs  Rate per 1,000 population (95% confidence intervals (CI))  Number of ambulance call-outs  Rate per 1,000 population (95% CI)  2009  31,292  789 (785, 793)  138,527  200 (199, 201)  2010  31,530  777 (773, 781)  147,557  207 (206, 208)  2011  32,045  779 (775, 783)  155,758  212 (211, 212)  2012  33,062  795 (791, 799)  164,673  215 (214, 215)  2013  33,139  788 (784, 792)  167,675  211 (210, 212)  Among RACF-residents there was a persistently higher rate of ambulance attendances for men than women with a rate ratio of 1.39. This is in comparison to the community-dwelling population where the rate of attendances was similar between sexes (rate ratio 1.03; Supplementary Table S2, available in Age and Ageing online). Demand peaked at over 1,000 attendances per 1,000-people among RACF-residents aged 80–84 years (Supplementary Table S3, available in Age and Ageing online), equating to at least one attendance per RACF-dwelling person of that age per-year. With increasing age, RACF-residents experienced increased attendance rates up to 80–84 years (Supplementary Table S3, available in Age and Ageing online), rates then declined slightly. In comparison, the community-dwelling group experienced a consistent increase in demand with age, across all age-groups (Supplementary Figure S2, available in Age and Ageing online). There was demonstrable variability in ambulance usage according to season with the highest rates during winter, July–September; and lower rates during summer, January–March (Figure 1). This variability in demand was far more pronounced among the RACF-population than the community-dwelling groups who experienced only slight rate fluctuations across the year (Figure 1). Figure 1. View largeDownload slide Rates per 1,000 population of ambulance attendance for 65+ year-old RACF-and community-dwelling population in Victoria by quarter and sex from 20. Figure 1. View largeDownload slide Rates per 1,000 population of ambulance attendance for 65+ year-old RACF-and community-dwelling population in Victoria by quarter and sex from 20. Discussion To our knowledge, this is the first study to describe rates of emergency-ambulance use by a highly vulnerable patient group, older people living in RACFs. It reveals whole-of-system demand, over a 5-year period for ambulance services by this sub-population and trends in rates over time. Ambulance attendance to RACF-dwelling people is up to four-times that of age- and sex-matched community-dwelling people and novel patterns in demand are described, in particular greater use by men, and during winter, with notable variation in attendance rates with age. We acknowledge some limitations. This retrospective analysis of routinely collected data relies on accurate documentation by paramedics and administrators at the time of patient interaction. In this study, demand from older RACF-dwelling people was very high, but consistent with internationally reported rates of ED-presentation and unplanned hospital admissions [5, 13]. Therefore, it is likely that these findings reflect global trends. Compared with community-dwelling people, those in RACFs experienced up to four-times greater ambulance usage. There are probable patient and health-system contributors to this disparity. Older RACF-dwelling people are likely to have poorer health, higher burden of chronic illness, frailty and cognitive impairment; all of which increase susceptibility to acute illness, falls and injury [4, 14]. Additionally, these conditions add complexity to clinical assessment, perhaps leading to a lower threshold to call an ambulance. This may be exacerbated by RACF-staffing patterns where personal-care attendants predominate alongside limited numbers of registered nurses and sessional doctors’ visits [4, 15]. Physical and cognitive disabilities may also increase the logistical complexity of medical investigations such as x-rays. Some mobile services attend RACFs, but elsewhere these involve transport to a secondary site, necessitating additional equipment, vehicles and staff-escorts. This may lead RACF-staff to call an ambulance to facilitate assessment. Access to community services may also be limited to certain times and days. Ambulance use by RACF residents is relatively consistent across all days of the week with evening peaks in demand [16]. This may fall outside standard hours for General Practitioners and out-reach services, leading to alternate use of ambulances. Our results demonstrate a seasonal effect with peak rates in winter and lowest demand in summer. This fluctuation was more pronounced for RACF-dwelling compared community-dwelling people. Older RACF populations may be more vulnerable to infectious disease, have higher rates of resistant organisms, and variable prevalence of immunisations [7, 17, 18]. Seasonal variation may therefore reflect heightened susceptibility to illnesses such as influenza, or less health reserve leading to greater disease severity, necessitating emergency care. Additionally, with close-living quarters or limited staffing resources calling an ambulance may provide an easier alternative to ongoing care within the RACF. Our study demonstrates a clear difference in ambulance attendance rates between older women and men living in RACF, but not the community. Similar differences have been suggested previously [2, 4, 19] though the cause remains unclear. It is possible that ambulances are being either under-utilised by one sex or over-utilised by the other. With higher rates of cognitive impairment, impaired mobility and institutionalised behaviour, older RACF-dwelling people are more dependent on staff to recognise an acute health deterioration and call an ambulance. The disparity suggests gender bias in the perception of, and response to, acute injury or illness in older RACF-patients by care- and/or health-workers. Factors contributing to this may include differences in clinical signs, behaviour patterns and coping strategies between women and men, which may influence interactions between patients and healthcare professionals. Previous studies have reported significant sex-differences in experience of illness, symptom-reporting and healthcare seeking behaviour [20, 21]. Whilst important, these factors are insufficient to adequately explain this difference in demand. The possibility that the threshold to seek emergency-care for men is lower than it is for women cannot be discounted. Conclusion This study provides robust evidence of very high rates of emergency-ambulance use by older RACF-dwelling people. Rates remained constant over the study period associated with a yearly increase in absolute ambulance use, a trend that is expected to persist. On a macro-level, these results provide clear evidence of associations between ambulance attendance and place of residence, sex, age and season, essential for effective health-service planning. Older RACF-dwelling people are a unique and growing patient group within the emergency healthcare system. Further research is needed to better describe clinical patterns of acute-illness and need for medical intervention to elucidate optimal modes of emergency-care for these vulnerable patients. This will also be beneficial in addressing gaps in training of RACF-staff to respond to acute health concerns, and in development of institutional guidelines for both RACFs and EMS. Additional studies are needed to evaluate individual healthcare interventions, including advanced care directives, on emergency ambulance demand. Key points Older RACF dwelling people are highly vulnerable patients. Their emergency care may be complex and have unintended negative consequences for individual patients and health system. RACF dwelling older patients have a very high rate of ambulance use. Rate of ambulance use is greater than that of community-dwelling people and varies according to age, sex and time of year. Supplementary data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Conflict of interest K. Smith is Director of the Centre for Research and Evaluation at Ambulance Victoria. Funding R. Dwyer is supported by a Monash University Faculty Postgraduate Research Scholarship. References 1 Carter MW, Datti B, Winters JM. ED visits by older adults for ambulatory care-sensitive and supply-sensitive conditions. Am J Emerg Med  2006; 24: 428– 34. Google Scholar CrossRef Search ADS PubMed  2 Lowthian J, Jolley D, Curtis A et al.  . The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995–2015. MJA  2011; 194: 574– 8. Google Scholar PubMed  3 Arendts G, Dickson C, Howard K, Quine S. Transfer from residential aged care to emergency departments: an analysis of patient outcomes. Intern Med J  2012; 42: 75– 82. Google Scholar CrossRef Search ADS PubMed  4 Dwyer R, Stoelwinder J, Gabbe B, Lowthian J. 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Economic burden of influenza-like illness in long-term-care facilities. Am J Health Syst Pharm  2001; 58: 1133– 8. Google Scholar PubMed  18 Lautenbach E, Fishman NO, Bilker WB et al.  . Risk factors for fluoroquinolone resistance in nosocomial Escherichia coli and Klebsiella pneumoniae infections. Arch Intern Med  2002; 162: 2469– 77. Google Scholar CrossRef Search ADS PubMed  19 Graverholt B, Riise T, Jamtvedt G, Ranhoff AH, Kruger K, Nortvedt MW. Acute hospital admissions among nursing home residents: a population-based observational study. BMC Health Serv Res  2011; 11: 126. Google Scholar CrossRef Search ADS PubMed  20 Macintyre S, Hunt K, Sweeting H. Gender differences in health: are things really as simple as they seem? Soc Sci Med  1996; 42: 617– 24. Google Scholar CrossRef Search ADS PubMed  21 Canto J, Goldberg RJ, Hand M et al.  . Symptom presentation of women with acute coronary syndromes. Arch Intern Med  2007; 167: 2405– 13. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Age and AgeingOxford University Press

Published: Apr 24, 2018

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