The study, published in BMC Geriatrics, analysed 8,208 ambulance assignments involving adults aged 65 and older in the Stockholm region between 2017 and 2019. All of these patients met strict clinical criteria for direct prehospital conveyance to a geriatric unit: they had urgent but non-life-threatening conditions, vital signs within normal reference ranges, and one of twelve predefined conditions considered suitable for geriatric assessment outside the emergency department. Despite this careful standardisation of patient eligibility, only 603 patients, roughly 7 percent of the sample, were actually conveyed directly to a geriatric unit. The remainder were taken to emergency departments, the default destination for most ambulance transports.

The headline finding is the sheer scale of geographic variation. Across the eight hospital service areas included in the analysis, each anchored by a distinct geriatric unit, crude conveyance rates ranged from 4 percent to 21 percent. In other words, a clinically similar older adult was more than five times as likely to be taken straight to geriatric care in some parts of Stockholm as in others. To disentangle what might be driving this pattern, the researchers employed multilevel logistic regression, a statistical framework designed for data with a nested structure, in this case patients clustered within hospital service areas. Random intercepts for each area allowed the probability of direct admission to vary geographically, while a suite of measures quantified the magnitude of that variation.

The technical vocabulary of the paper rewards attention. The intraclass correlation coefficient, or ICC, estimated that around 10 percent of the total variation in conveyance outcomes was attributable to differences between areas in the unadjusted model. The median odds ratio, or MOR, translates area-level variance into a more intuitive quantity: in the fully adjusted model, an MOR of 1.54 means that two otherwise identical patients living in different hospital service areas could face odds of direct geriatric admission differing by a factor of 1.54, simply as a function of residence. The proportional change in variance, or PCV, tracked how much of the between-area variation disappeared as successive covariates were added to the models.

Crucially, the researchers separated potential explanations into demand-side factors, which reflect patient characteristics and healthcare need, and supply-side factors, which reflect the organisation and capacity of the care system itself. The demand-side variables included age, sex, socioeconomic status, living conditions, comorbidity burden, and previous hospitalisation. The results were striking: adjusting for these patient characteristics did not shrink the geographic variation at all. In fact, the between-area variance increased slightly, by nearly 9 percent, suggesting that differences in patient mix between areas actually masked rather than explained the true extent of the disparity. Where older people live matters for their access to geriatric care, and it is not because they are sicker or different in ways the registers can capture.

Supply-side factors told a different story. Three variables stood out as correlates of the observed heterogeneity. Geographic proximity to a geriatric unit reduced the estimated between-area variance by 26 percent, consistent with a well-documented tendency of ambulance crews to convey patients to the nearest suitable facility when distance differentials widen. Ownership of the geriatric unit, whether public or private, was associated with a 27 percent reduction in variance, although this finding proved fragile under alternative statistical approaches. Most powerfully, the number of staffed geriatric beds in an area reduced the between-area variance by 38 percent, implying that capacity itself, the sheer availability of specialised beds, shapes who gains access to this form of care. In the fully adjusted model combining all demand- and supply-side factors, the between-area variance fell by 41 percent, yet a substantial residual disparity remained.

The study also examined timing, finding that conveyance during office hours was significantly associated with direct geriatric admission, even though it did not explain the differences between areas. This pattern echoes previous research suggesting that out-of-hours conveyance rates drop when diagnostic support, laboratory access, and staffing are reduced, and when ambulance personnel feel heightened responsibility for patient safety. An incorrect decision not to convey an older person could lead to adverse health events, while a defensive decision to send everyone to the emergency department wastes resources and exposes frail patients to environments poorly suited to their needs. Emergency departments, designed for rapid assessment of acute single conditions, have been shown in prior studies to place older adults at risk of long waits, fragmented care, and functional decline, particularly for those with multimorbidity, frailty, or geriatric syndromes such as falls and delirium.

The stakes of this routing question are underscored by an accumulating evidence base on geriatric units themselves. Comprehensive geriatric assessment delivered by interdisciplinary teams has been associated with improved functional status and reduced institutionalisation compared with usual care pathways. Research from France has suggested that direct admission to acute geriatric units, bypassing the emergency department, may shorten length of stay, reduce post-acute transfers, and even prove cost-effective for selected patients. In Stockholm, a prehospital decision support system in use since 2011 directs older patients with specific conditions and mild acute illnesses toward alternative care pathways, including direct conveyance to geriatric units, and patients receiving such direct care have expressed satisfaction with it, typically remaining at the geriatric unit for their entire care episode.

The authors are careful about the limits of their findings. With only eight hospital service areas, variance estimates in multilevel logistic models can be biased and imprecise, and the team tested this vulnerability with three robustness analyses, including a Bayesian multilevel model with weakly informative priors. That Bayesian analysis produced a posterior mean variance roughly twice that of the primary frequentist estimate, with a wide highest posterior density interval, indicating substantial uncertainty around the magnitude of the geographic variation and around the specific contribution of unit ownership. The authors also note that the study lacked measures of organisational factors such as real-time bed availability, laboratory capacity, and diversion practices, as well as data on cognitive impairment and functional status, any of which could contribute to the unexplained residual variation. Distance was calculated from residential addresses rather than actual pickup locations, and the study measured conveyance rather than patient outcomes.

Even with these caveats, the implications are difficult to ignore. In a universal, tax-funded healthcare system like Sweden’s, where all accredited providers operate under the same regulatory and reimbursement rules, one might expect access to specialised care pathways to be relatively uniform. Instead, the study suggests that the geography of geriatric bed capacity and the location of units themselves may quietly ration access to a form of care that clinical evidence favours for frail older adults. The authors point toward practical levers: reviewing why non-conveyance to geriatric units rises outside office hours, and considering how the placement and capacity of geriatric services might be planned to support more consistent and equitable pathways. At the same time, they caution against naive capacity expansion, since supply-sensitive utilisation is a well-known phenomenon in health services research. The deeper message is that for older adults, the emergency care pathway begins not at the hospital door but in the ambulance, and the organisation of what lies downstream of that first decision deserves the same scrutiny as any hospital intervention.

Subject of Research: Geographic variation in direct ambulance conveyance of older adults to geriatric units versus emergency departments in Stockholm, Sweden

Article Title: Disparities in direct access to acute geriatric care – an observational analysis of geographic variations of ambulance conveyance

Article References: Varg, S., Vicente, V., Hagman, M., Johansson, N., Lindgren, P., Heintz, E., & Rehnberg, C. (2026). Disparities in direct access to acute geriatric care – an observational analysis of geographic variations of ambulance conveyance. BMC Geriatrics, 26(1), Article 1244. https://doi.org/10.1186/s12877-026-08370-1

Image Credits: AI Generated

DOI: 10.1186/s12877-026-08370-1

Keywords: geriatric care, ambulance services, emergency department, geographic variation, older adults, prehospital care, hospital service areas, health equity, multilevel modelling, Sweden, emergency medical services, bed capacity