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. 2025 Sep 2;8(9):e2531166.
doi: 10.1001/jamanetworkopen.2025.31166.

Caregiver Burden and 30-Day Emergency Department Revisits

Nathalie Germain  1   2   3 , Annie Toulouse-Fournier  1   3 , Rawane Samb  1 , Émilie Côté  1 , Vanessa Couture  1 , Stéphane Turcotte  1 , Michèle Morin  1   2 , Yves Couturier  4 , Lucas B Chartier  5 , Nadia Sourial  6 , Samir K Sinha  7   8   9 , Don Melady  7   10 , Marie-Soleil Hardy  1   3   11 , Richard Fleet  1   2   3   12 , France Légaré  2   3   12   13 , Denis A Roy  6 , Holly O Witteman  2   3   12 , Éric Mercier  2   12   13 , Josée Rivard  1 , Marie-Josée Sirois  2   3   14 , Joanie Robitaille  1 , Patrick M Archambault  1   2   3   12 ; LEARNING WISDOM investigators for the Network of Canadian Emergency Researchers
Collaborators, Affiliations

Caregiver Burden and 30-Day Emergency Department Revisits

Nathalie Germain et al. JAMA Netw Open. .

Abstract

Importance: Caregivers of community-dwelling older adults play a protective role in emergency department (ED) care transitions. When the demands of caregiving result in caregiver burden, ED returns can ensue.

Objective: To develop models describing whether caregiver burden is associated with ED revisits and hospital admissions up to 30 days after discharge from an initial ED visit.

Design, setting, and participants: This prospective cohort study nested within the LEARNING WISDOM longitudinal cohort study included dyads of community-dwelling patients aged 65 years or older and their caregivers. Included patients were triaged to an observation unit stretcher on their index visit to 1 of 4 EDs within an integrated health multisite organization of 4 acute care hospitals in Québec, Canada, between January 1, 2019, and December 21, 2021, and underwent a transition of care when discharged back to the community. Analyses were conducted in May 2024.

Exposure: Caregiver burden, collected using the brief 12-item Quebec French version of the Zarit Burden Interview (ZBI; score range, 0-48, with higher scores indicating higher burden).

Main outcomes and measures: Revisits to the ED, defined as a return to any ED in the 4-hospital network, within 3, 7, or 30 days of the index visit and return visits to the ED resulting in hospitalization within 30 days of the index visit. Moderation of outcomes by wave of the COVID-19 pandemic at the index visit was also assessed.

Results: Among 1409 caregiver-patient dyads, 711 patients (50.5%) and 980 caregivers (69.6%) were women; mean (SD) age was 77.06 (7.39) years for patients and 63.87 (12.04) years for caregivers. The mean (SD) ZBI score was 7.33 (7.11). Caregivers were most often spouses of patients (667 [48.0%]) or children of patients (534 [37.9%]). Among all patients, 75 (5.3%) returned to the ED within 3 days, 133 (9.4%) returned within 7 days, 292 (20.7%) returned within 30 days, and 88 (6.2%) were admitted to the hospital within 30 days. Each point increase on the ZBI scale was associated with an increase in the odds of a 30-day revisit to the ED (odds ratio [OR], 1.03; 95% CI, 1.00-1.05; P = .03), but associations were not found in models with shorter time windows (3 days: OR, 1.01; 95% CI, 0.98-1.04; P = .69; 7 days: OR, 1.01; 95% CI, 0.98-1.03; P = .55) or for revisits with hospital admissions (OR, 1.02; 95% CI, 0.99-1.05; P = .24). Associations between ZBI scores and 30-day ED revisits may have been moderated by the COVID-19 pandemic waves: the first interwave period (between waves 1 and 2) reversed the association (OR, 0.89; 95% CI, 0.78-0.97).

Conclusions and relevance: The findings suggest caregiver burden may be associated with ED revisits within 30 days of discharge from an initial ED visit among community-dwelling older adults. Future studies could enhance the management of ED revisits by demonstrating the longitudinal impact of caregiver burden on ED use in older adults.

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Conflict of interest statement

Conflict of Interest Disclosures: Ms Germain reported being employed by Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) outside the submitted work. Ms Toulouse-Fournier reported receiving grants from the CIHR, Fonds de Recherche du Québec–Santé, VITAM-Centre de recherche en santé durable, and Centre de recherche intégrée pour un système apprenant en santé et services sociaux du CISSS-CA outside the submitted work. Dr Witteman reported receiving grants from the Canada Research Chairs Program, the CIHR, the Canada Foundation for Innovation, and Breakthrough T1D Canada and personal fees from Elsevier for peer review activities outside the submitted work. Dr Archambault reported receiving grants from the CIHR and Fonds de Recherche du Québec–Santé during the conduct of the study and research funding from AstraZeneca for a clinical trial outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart Describing Recruitment of Patients and Their Caregivers
ZBI indicates 12-Item Zarit Burden Interview.
Figure 2.
Figure 2.. Moderation of Associations of 12-Item Zarit Burden Interview (ZBI) Scores and COVID-19 Periods With Odds of 30-Day Emergency Department Revisit
COVID-19 waves correspond to the Institut national de santé publique du Québec definitions of the COVID-19 timeline in Québec: wave 1, March 13 to July 11, 2020; wave 2, August 23, 2020, to March 20, 2021; wave 3, March 21 to July 17, 2021; wave 4, July 18, 2021, to December 4, 2021. OR indicates odds ratio.
Figure 3.
Figure 3.. Receiver Operating Characteristic Curves for Each Logistic Regression Model
A, Factors included 12-Item Zarit Burden Interview (ZBI) score, number of emergency department (ED) visits in the previous year, and the COVID-19 period (which interacted with both ZBI score and past-year ED visits). B, Factors included number of ED visits in the previous year, male patient sex, caregiver living in a care home, and Canadian Triage and Acuity Scale (CTAS) triage level below 5 on a scale of 1 to 5 (CTAS 1 requires immediate care and CTAS 5 requires nonurgent care). C, Factors included number of ED visits in the previous year, caregiver living in a care home, a CTAS triage score below 5, and time on a stretcher at the index ED visit. D, Factors included walk-in arrival at the index ED visit, Charlson Comorbidity Index score, annual caregiver income.
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