Marginal Dispositions and Shared Decision-Making Among Older Adults in the ED: A Prospective Cohort Study.

Abstract

ED disposition decisions for older adults are complex and often uncertain, yet studies rarely capture emergency physicians' real-time perspectives. To assess patient outcomes based on emergency physician-perceived need for admission. Single-site prospective cohort study conducted between July and November 2024. A Boston-area academic tertiary care ED. Patients aged 65 and older dispositioned by attending physicians, excluding patients who were handed off, left without being seen, or eloped. Physicians rated admission need using a 5-point Likert scale (2-4 considered marginal). Primary outcome was ED disposition stratified by rating. Secondary outcomes were hospital length-of-stay (LOS), 7-day ED return, and 30-day mortality. Of the 489 patients (mean age 76.9 years [SD 7.5], 51.1% female), 55.8% were non-marginal admissions, 26.0% were non-marginal discharges, and 18.2% were marginal dispositions. Patients with marginal dispositions had longer workup times than non-marginal admissions or discharges (3.3 vs. 2.8 vs. 2.4 h, p < 0.05). Thirty-day mortality was greater for non-marginal admissions (8.8%) than non-marginal discharges (1.6%, p = 0.01), but not significantly different than marginal dispositions (3.4%). Marginal admissions had shorter median LOS (3.1 vs. 5 days, p < 0.01) and higher early discharge rates (27.8% vs. 13.2%, p = 0.01) than non-marginal admissions. Marginal discharges had fewer 7-day returns than non-marginal discharges (0% vs. 11.7%, p = 0.04). For marginal cases, physicians discussed admission benefits more than risks (70.1% vs. 43.3%, p < 0.01) for marginal cases. Single-site and need for admission were reported contemporaneous with disposition decision. One in six older adult ED dispositions was identified as marginal. These patients are potential targets for shared decision-making and alternative care pathways.