Increasing demand for emergency patient services: underlying drivers,implications and potential solutions

The rise in demand for emergency patient services is a significant issue for the health system. The ever increasing burden on emergency transportation services, emergency departments (EDs) and acute hospitals has implications for resourcing and the quality of care delivered. Governments and service providers have responded with various strategies, however demand for emergency healthcare continues to rise. Ageing of the population is also an important issue for health service planning. Reviews of the international and national literature of trends in the utilisation of emergency ambulance and ED services suggested numerous factors including ageing were associated with the rise in emergency demand. However it was apparent that emergency demand had not been investigated systematically from an epidemiological perspective. Therefore the aim of this thesis was to analyse the main elements of the persistent rise in demand across metropolitan Melbourne, with a particular focus on clarifying how the ageing population impacts on emergency demand. Longitudinal analyses was undertaken, of emergency ambulance transportations,ED presentations and admissions to hospitals through EDs using unique population-based datasets. Numbers and rates of emergency ambulance transportations, ED presentations and emergency admissions from EDs; and ED and hospital length of stay were analysed. Regression models evaluated the effects of multiple factors on these outcomes. The volume and rates of utilisation of all emergency health care services over the study periods increased beyond that expected from changes in population growth and ageing. The study of emergency ambulance transportations provides new evidence about an acceleration in usage by the elderly. All emergency transportations rose by an average annual rate of 4.8%. Predictive modelling suggested further increase up to 69% by 2015. Investigation of the trends in all ED presentations were analysed and demonstrated a similar increasing disproportionate representation of the elderly over a 10 year period. It was also established that a subgroup of the elderly make multiple visits to EDs; and over 50% of elderly patients are admitted to hospital following ED presentation. The overall average annual rate of increase in ED presentations by all age groups was 3.6%. ED length of stay increased over the study period for those who were older, more acutely unwell, and required hospital admission. As it was not possible to understand all the factors associated with the rise in ED presentations, a descriptive study explored patient perspectives through qualitative interviews. Reduced accessibility to general practitioners and an expectation of timely accessible specialist care were the main reasons underpinning their attendance at a metropolitan ED. Further analysis of patients admitted to hospital from EDs discovered that the growth in emergency hospital admissions was driven by a 60% increase in the number of single day/overnight admissions. This represented an average growth rate of 6.1% per year. This rise in short-stay hospital admissions from EDs may signal that there has been a shift in patterns of care in the ED. It also raises the question of whether ED attendance by this group of patients was necessary. The significance of this thesis is the identification and measurement of the rise in emergency demand, but with an increasing and accelerating usage of emergency health services by older patients, together with a growing propensity of this subgroup re-present to EDs over time. With population ageing, demand by the elderly will continue to rise and will have a dramatic impact on all elements of emergency healthcare in the future. This information is valuable for policy makers and service providers. It indicates a pressing need to consider how to develop coordinated systems of care, particularly for the elderly seeking acute care.