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| Journal of the New Zealand Medical Association,
19-May-2006, Vol 119 No 1234
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After hours healthcare for older patients in New
Zealand
Anne Eastwood, Anthony Dowell
Most research and policy documents relating to the health of
older people focus on chronic and degenerative conditions, rather than access
to, and use of, health services.1–3 Older people suffer acute health
problems and may benefit more from treatment than younger people. Campbell4
refers to the “threshold effect” in which many older people are
close to a point where further small losses of function will seriously affect
their independence. Thus it is important to determine how older people use acute
care services and whether there are barriers to their access.
Little research into ED and after hours clinic-use exists,
and most of it is not specific to older people and is conducted outside New
Zealand.5,6. In the UK, Foster et al7 found that a stoical attitude towards
health, difficulties with transport, reluctance to go out at night, and a
preference for a familiar doctor were factors contributing to a reluctance
amongst the elderly to seek after hours medical care.
The absence of accurate New Zealand prevalence data for
attendance at after hours services in this older age group indicated a need to
explore this issue. . There was also anecdotal evidence from the Hutt Valley
area of New Zealand that some older people were deferring seeking healthcare
when they became unwell after hours, with resulting adverse consequences for
their long-term health.
MethodsThe research was conducted in the Hutt Valley where 11%
of the 131,000 residents were aged 65 and over (compared with 12.9% of the New
Zealand population) and where there is a somewhat higher standard of living than
the New Zealand average.8–10 Existing sources revealed that Lower Hutt was
relatively under-doctored, with Wainuiomata having a particularly low number of
general practitioners.11 The leading causes of hospitalisation and mortality for
the Hutt Valley were similar to those nationally.11 The Hutt Valley District
Health Board (HVDHB) had higher avoidable morbidity rates for 65 to 74 year olds
than many other DHBs.3
Older age was
defined as 65 years and over. This is consistent with New Zealand statistical
data, the age of eligibility for National Superannuation, and much of the
published research. “After Hours” was defined as between 1730 and
0800 hours.
Data was obtained for the year 2002, from two after
hours clinics (AHCs). Information was gathered from MedTech 32 software using
“Query Builder”. All adult attendances were captured and broken down
by gender, with the elderly group in 10-year age bands (65 to 74, 75 to 84, and
85 and over).
Information was available from all visits to the Hutt
Hospital Emergency Department (ED) in 2002. The data was entered into SPSS
version 10 for analysis. Chi-squared tests of association or two-tailed z tests
for comparing rates13 were carried out on selected variables. ED figures include
all non-elective, non-obstetric admissions to the hospital. Patients who had
been referred by a GP were therefore excluded. Not all patients who saw a GP
after hours were captured, since two practices undertook their own after hours
care at that time. Overall, these practices, with a combined practice population
of 30,000, have a similar combined age/sex profile to the rest of the Hutt
Valley.
ResultsAttendance rates were reviewed from 38,979 AHC visits
(comprising 34,371 visits from 15 to 64 year olds, and 4608 from those aged 65
and older),and 24,065 ED attendances (comprising 18,821 visits from 15 to 64
year olds, and 5244 from those aged 65 and older).
Attendance rates at the after hours clinics were
significantly greater for older people (≥65 years) and for women.
Meanwhile at after hours EDs, attendance rates for older people were greater
and, unlike after hours clinics, rates for men were greater than for women. (Table
1)
The lowest AHC attendances were in the 65 to 74 year age
group, at 248 per 1000 for men and 270 per 1000 for women. Modelling the
relationship between after hours attendance rates and age group, gender and
place of attendance using a Poisson regression showed that (compared to the
youngest age group) this decrease was significant (p<0.001).
Figure 1 shows the arrival time patterns for older and
younger people. Although the shapes of the graphs are similar, there is a
significant difference in the
pattern of arrival
over time, with older people more likely to attend in the middle of the day and
less likely to attend at night. (χ²=200.0, df=11, p<0.001).
Figure 1. Time of ED arrival by age group
 A higher proportion of
ED attendances by
older people arrived there by ambulance after hours (63.5%) than in normal hours
(47.9%) (χ²=118.4,df=1, p<0.001.). There was a significant increase
in the proportion of attendances arriving by ambulance with age, with 36.0%,
50.1%, and
68.0% of older
people in the three age groups arriving by ambulance in normal hours—and
51.5%, 69.6%, and 78.1% arriving after hours (χ² for linear
trend=248.1,df=1, p<0.001). In 2002, 23% of all arrivals at Hutt Hospital ED
came by ambulance.
Although the admission rate is an index of the severity of
the presenting complaints in an age cohort, it can be influenced by factors such
as the availability of beds and social circumstances. The rates of admission
from ED are shown in Table 2.
Table 2. Admission rates by age group 2002. Rates per
1000 population* (with 95% confidence limits)
*Rates throughout are age
and gender specific, based on 2001 Census figures.
Older people are significantly more likely to be admitted
than younger people and the rate of admission increases with increasing age of
older people. In all age groups, the proportion of admitted attendances is very
similar in normal hours and after hours. Older men have higher admission rates
than older women both in normal hours and after hours, but this difference is
significant only in the 75 to 84-year-old age group.
On arrival at ED, patients are assigned a triage code
indicating the severity of their condition, with code 1 being the most severe.
Analysis by triage code showed similar trends to that by admission. For all age
groups of elderly, a significantly higher (Chi-squared) proportion of ED
attendances had triage codes 1 to 3 after hours than in normal hours (72%
compared with 59% for age
65-74
(χ²=32.6, 1 df, p<0.001) 74% compared to 62% for age 75-84
(χ²=32.6, 1 df, p<0.001) and 70% compared with 61% for age
85+(χ²=7.1, 1df, p=0.008)).
Attendance as the result of an accident (when an ACC form
was completed) was also analysed for differences between older and younger
people, and for differences between after hours and normal hours.
Older men (aged 65 and older) attended ED with accidents at
a rate significantly less than that of younger men (15 to 64) both in normal
hours (53 per 1000 compared with 92 per 1000 (z=9.55, p<0.001)) and after
hours (14 per 1000 compared with 23 per1000 (z=10.69, p<0.001)). Older women
presented with injuries at higher rates than younger women, in normal hours (63
per 1000 compared to 42 per 1000 [z=9.96, p<0.001]), but there was no
significant difference after hours (22 and 24 per 1000).
The
elderly population of the Hutt Valley is predominantly (91%) European, but data
from the three largest minority ethnic older populations (Asian 3.7%, Māori
2.8%, and Pacific 2.6%) was also obtained.
Table 3. ED attendances by older people by ethnicity
and gender. Rates per 1000 population* (with 95% confidence limits)
*Rates are specific to
ethnic group.
Older Europeans had after hours attendance rates which were
significantly different from those in normal hours. After hours,
Māori, and
Pacific older people had significantly higher rates of admission (134 and 122
per 1000 compared with 83 for European, p<0.05; significance determined by
non- overlapping 95% confidence intervals for all ethnicity data) and were
assigned the highest triage codes (191 and 138 per 1000 for codes 1 to 3
respectively) compared to 93 for European (p<0.05), but in normal hours there
were no significant differences.
Older Asian people presented to ED significantly less often
than other ethnic groups both in normal hours and after hours, had the lowest
proportion of triage codes 1 to3 (58 per 1000 in normal hours and 59 per 1000
after hours compared with 142 and 93 for European), were admitted less often (60
and 49 per 1000 compared with 140 and 83 for European) and arrived less often by
ambulance (24 and 26 per 1000 compared with 114 and 85 for European). There were
no significant differences between ethnic groups in their attendance with
accidents after hours.
Discussion
This paper demonstrates significant differences between
different age groups in their use of after hours services, raising issues for
health service planners about service provision and also about what constitutes
“appropriate” demand for services at any particular time of the day
or night. Given the known increased rates of morbidity with increasing age the
relative low presentation by “younger” old people may represent a
service gap, or reflect their ability to access services during the day.
These New Zealand findings from AHCs, are consistent with
previous research conducted in the U.K by Foster et al.7 Men and the
“young-old” are particularly under-represented in AHC attendances.
The 1996/7 NZ Health Survey14 found that the “young-old” were more
likely than younger people to have attended a general practitioner (GP) at least
once in the previous year and to have been frequent users of GP services. It
also found that older men were only slightly less likely than older women to
have visited their GP in the previous year, and were more likely to be frequent
attenders. The 2002/3 NZ Health Survey15 also found high rates of GP attendance
in older people. The lower attendance of the “young-old” and men at
after hours clinics does not reflect the general trend in GP
consultations.
Older people (especially men) presented to ED at a higher
rate than younger people. This is consistent with findings in Australia16 and
the UK.17 However rates for the “young-old’ are similar to those for
younger people. This suggests that the low rate of consultation by the
“young-old” at after hours clinics does not just represent a
preference for ED. Admission rates and triage codes suggest a higher rate of
serious illness in older people, particularly after hours. This was also found
by Chu et al16 in Australia.
Older
Europeans attended ED at much lower rates after hours than in normal hours. This
trend is not seen in other ethnic groups, except for Māori men who had the
highest rate of attendance in normal hours. The 2002/3 NZ Health Survey15
also found that adult Asians accessed many health services at a comparatively
low rate. The tendency to use ED for accidents has been described
elsewhere.18,19
A particular reluctance of the “young-old” to
seek after hours care does not appear to have been described elsewhere in the
international literature. The low attendance of recently retired people at after
hours services may be due to the relative ease with which they can access day
time healthcare. The steady increase in consultation with advancing age beyond
75 should at least partly be explained by increasing morbidity and a greater
tendency to live in the care of a relative or institution, which may influence
the decision to seek care.
This study did not consider outcomes. It is also not known
whether the pattern of attendance of either younger or older people is
“appropriate”. It may be that the lower use of after hours services
by some groups of older people is appropriate, rather than representing a
service gap. The definition of appropriate health service use is
difficult.
The transferability of the current study’s findings to
communities outside the Hutt Valley is uncertain. While this elderly population
is statistically reasonably representative of the New Zealand elderly, small
differences, for example in income levels (indicated by lower than average CSC
holding) could be reflected in the study’s results.
The free service provided by the Wellington Free Ambulance
may have had a significant effect on the use of after hours services by the Hutt
Valley elderly.
Information could not be obtained from two practices
providing their own after hours services. Total service use and the rates, which
are based on the overall population, cannot thus be generalised to other
districts in the country.
Possible reasons for the choices made by older people about
accessing after hours care may include cost, transport difficulties, difficulty
interpreting symptoms, and established healthcare-seeking behaviours. Given the
time course of many episodes of acute illness, particularly against a background
of chronic morbidity, it is possible that there is an element of stoicism by
older people to “wait for normal hours”. Older people may need
education and encouragement to attend after hours services and GPs and other
providers cannot assume that older people will respond to acute illness in the
same way as younger people.
Further qualitative information is required to interpret
these findings and hence work towards appropriate levels of service provision
and patient education. This will be a theme of future work.
Author information:
Anne Eastwood, General Practitioner and Medical Educator, Royal Australian
College of General Practitioners and University of New South Wales (RACGP and
UNSW), Sydney, Australia; Anthony Dowell, Professor and Head of Department,
Primary Health Care and General Practice, Wellington School of Medicine and
Health Sciences, University of Otago, Wellington
Acknowledgements:
Anne Eastwood completed this research (part of a Master of General
Practice degree) with support from a University of Otago Postgraduate Award. We
also thank Clare Salmond (Biostatistician, Wellington School of Medicine and
Health Sciences); Donald Mackie (Clinical Head – Emergency Department,
Hutt Valley District Health Board); Hutt Valley After Hours Medical Centre; and
the Upper Hutt After Hours Medical Centre for their assistance.
Correspondence: Dr
Anne Eastwood, NSW Refugee Health Service, PO Box 144, NSW 1871, Australia. Fax:
61 2 87780790; email: anne.eastwood@swsahs.nsw.gov.au
References:
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