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

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BACKGROUND: ED disposition decisions for older adults are complex and often uncertain, yet studies rarely capture emergency physicians' real-time perspectives. OBJECTIVE: To assess patient outcomes based on emergency physician-perceived need for admission. DESIGN: Single-site prospective cohort study conducted between July and November 2024. SETTING: A Boston-area academic tertiary care ED. PARTICIPANTS: Patients aged 65 and older dispositioned by attending physicians, excluding patients who were handed off, left without being seen, or eloped. MEASUREMENTS: 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. RESULTS: 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. LIMITATIONS: Single-site and need for admission were reported contemporaneous with disposition decision. CONCLUSIONS: One in six older adult ED dispositions was identified as marginal. These patients are potential targets for shared decision-making and alternative care pathways.

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