The Cognitive Determinants of Healthcare Utilization

Background and Purpose: While the research of pathways to increased utilization of Healthcare (specifically Emergency Department use) has shifted focus from medical needs to social determinants, the impact of diminished cognitive functioning as a factor in healthcare utilization is overlooked and discounted in interventions. To fill the knowledge gap and inform effective intervention design, this research aims to examine the association of cognitive impairments with emergency department utilization co-occurring in the setting of high-risk health and social determinant needs.

Methods: Statistical analysis was completed using de-identified adult data from the 2018 National Health Interview Survey collected by the Center for Disease Control (N= 24,663). The dependent variable is emergency department utilization in the previous 12 months reported by sample respondents (0= No visit and 1= at least one emergency department visit), and the independent variable is impaired cognition, defined as experiencing at least some level of difficulty with memory and concentration in the past 30 days. A logistic regression test was conducted adjusting for demographic factors (such as sex, age, race, region), socioeconomic backgrounds (income, education, employment status, marital status), health and social determinants (history of heart condition, stroke, diabetes, asthma, hypertension, difficulty affording medication, and health insurance status), and cognitive mood distortions (feeling restless, nervous, or depressed).

Results: Results: 35% of respondents with impaired cognition reported at least one visit to the emergency department in the past 12 months compared to 19% of respondents without impaired cognition. The bivariate logistic regression test yielded an odds ratio of 2.22 (p<.001): the odds of visiting emergency department for individuals with impaired cognition are 2.22 times of that for those without impaired cognition. This relationship remained statistically significant (OR=1.64, p<.05) when adjusting for demographic characteristics and health and social determinants. Among control variables, difficulty affording medication has the strongest association with the emergency department visits (OR= 2.16, p<.001).

Conclusion: The significant association between cognitive impairments and increased healthcare utilization suggests that cognitive impairment is an important factor to better understand the pathways to emergency department utilization. This relationship provides evidence for expanding the framework for reducing utilization to include a targeted focus on cognitive wellbeing. The associations between the variables controlling for health and social determinants with emergency department utilization confirm that comprehensive needs drive increased healthcare usage. Intervention programs designed to reduce utilization cannot rely on a singular focus but through a combination of establishing primary care, addressing social needs, and including a component that assesses cognitive functioning to determine ability to navigate care, healthcare systems can begin to effectively address disproportionate emergency department utilization.