Operation "Pop Drop"

Every home caregiver deserves a break, but finding substitutes is hard. What happens when there aren't any good options?

If you’ve ever worked in an emergency department or an inpatient hospital unit, there’s a good chance you’re familiar with the “pop drop”—if not the term, then the phenomenon. (And no, we’re not talking about the 2016 pop music fad).

Patients who live at home but require around-the-clock care tend to have a primary caregiver and perhaps some others who look after them. Caregivers are often family members, but they can also include home health aides, visiting nurses and therapists, and others who make it possible to live at home instead of, say, in a nursing home. There are many reasons a patient might require 24/7 care, and the care needs can be quite variable.

Providing such care is a lot of work for caregivers, many of whom gain expertise in managing complex medical conditions. It can be physically and emotionally demanding, stressful, expensive, and socially isolating. Without a doubt, caregivers need and deserve breaks, including vacations—but this can be easier said than done. To find respite care for the patient, caregivers in need of a break can reach out to family and friends, but they may not be able to cover all the necessary care. They can seek professional respite care as well, but it’s expensive and costs can add up quickly.

While likely not preferred, caregivers can also get a “break” if a patient ends up in the hospital with, for example, a complication of their chronic issues or a more serious problem like an infection. While patients are under our care in the hospital, it’s quite common for us to see caregivers taking the opportunity to catch up.

In medical slang, a “pop drop” is when a caregiver drops of a patient in the emergency department with a problem of questionable significance, knowing the patient will be taken care of for a stretch of time and giving them a break (“pop” referring to an elderly man). This break could last a few hours while the patient is evaluated in the emergency department, a few days if the patient ends up being admitted to the hospital, or even longer if the hospital care teams aren’t able to ensure that the patient is able to return home to a safe environment. If, for example, an essential home caregiver dropped off a patient without a serious medical problem at the emergency department on the Friday before a holiday weekend and went out of town, the hospital would have to care for the patient until they could send them home the following Tuesday.

We understand why a caregiver might want—or need—to take advantage of the care available at the hospital. For example, a 2017 study showed that when primary caregivers themselves were experiencing health problems, the patients they cared for used the emergency department more often.

But it did get us wondering: is the pop drop just a one-off story from a Friday evening shift in the ED, or is it a pervasive phenomenon?

Taking a look at the data

While it’s not hard to find stories of pop drops, identifying them in the data isn’t so straightforward. If we’re looking at insurance claims data, it’s impossible for us to know the motivations for why any individual patient presented for medical care. But if we look at days where we would expect a pop drop to be more likely, we might find evidence of a significant phenomenon.

In a collaboration with Swad Komanduri at RAND and Christopher Whaley at Brown, we started by taking a look at patients with Medicare in an analysis we’ve only shared here.

Specifically, we looked at patients who were admitted to the hospital at least twice in a year—a group of patients we figured could have complex enough medical problems that they could reasonably require care at home from caregivers who need a break. We also figured that a pop drop would be more likely to occur over a holiday weekend with the Monday off than a standard weekend, since caregivers may go out of town for the holiday (i.e., we might see greater-than-typical hospitalizations on the Friday, Saturday, or Sunday before the holiday Monday, i.e., the days of or leading up to the three-day weekend). Here’s what we found when we looked at the number of hospital admissions on any given day of the week:

Weeks are Sunday to Saturday. Standard, non-holiday weeks are in blue and set to 1 as a reference. The week before a holiday week is in orange, and the week of that holiday (where Monday is the holiday) is in gray, with bars representing admissions relative to a standard week. (Note the bottom of the vertical axis is at 85%).

We saw a few notable things here:

• Not surprisingly, there were fewer hospital admissions on holiday Mondays (in gray, above).

• In the days after that holiday Monday, there were more admissions than usual. This makes sense, as these days are likely compensating for the reduced admissions on the holiday Monday.

• There were some slight differences on the Friday, Saturday, and Sunday before a Monday holiday (in orange, above), but they weren’t dramatic and we certainly didn’t see clear evidence that hospitalization rates were higher on, for example, the Friday going into a three-day weekend. In fact, we were a bit surprised to see a small dip on the Friday, where we would have expected an increase, but perhaps these patients weren’t coming until the Saturday.

We didn’t feel we could make any definitive conclusions about pop drops from this analysis, so we went a little further. The next thing we did was limit our analysis to patients with Alzheimer’s dementia—a group more likely to have regular care at home. We then decided to look at some reasons why they were admitted to the hospital. One of these reasons is “dementia,” which is a chronic issue and is typically not the listed reason for hospital admission—unless there isn’t another more significant problem, which is what we might expect for a pop drop.

Here’s that additional analysis. Here, the colors are different and represent different reasons for hospital admission. The bars show the number of admissions on each day of the week in the week before a Monday holiday relative to a typical week for each condition:

Here, we saw a few more notable things:

• For admissions with dementia as a primary diagnosis—suggesting a more pressing acute problem was not present—we saw a similar pattern as before. A very slight dip on Friday and a slight increase on Saturday before a holiday, but not an impressive pattern (certainly, no evidence of higher hospitalization rates on Friday going into the three-day weekend).

• For GI hemorrhage (dark blue) and heart attacks (AMI in gray), there weren’t any differences in admissions before a holiday Monday.

• Hip fractures and joint dislocation admissions had a curious pattern leading up to and during the holiday weekend. And while we weren’t sure why this pattern existed, it didn’t seem like the pop drop phenomenon would explain it.

So are pop drops a real problem?

It’s hard to come to any definitive conclusions from this quick look at the data. But we didn’t see evidence of a large impact on holiday weekends, at least in the group of Medicare patients with dementia—a group that’s more likely to have higher demands on caregivers.

But because we were comparing holiday Fridays to typical Fridays, what we couldn’t see from this analysis is whether the pop drop phenomenon is a significant contributor to admissions every Friday; they may be. We also looked only at hospital admissions, since we were most interested in pop drops for a longer duration of respite. If we looked at emergency department visits where people were sent home after a few hours, it might be a different story.

So despite the anecdotes, we still don’t have a great sense of how common it is for caregivers to bring patients to the hospital with minor issues for un-official respite care. While we as medical providers may believe a caregiver is bringing a patient in with a minor complaint just for a break, we shouldn’t assume that there isn’t a serious problem underlying a subtle change. Often times in these complex patients that require around the clock care, a seemingly “minor” symptom that prompted someone who knows the patient well to bring the patient in was the only clue to a serious underlying problem.

But it’s also important to remember that even if pop drops are happening and may be perceived as an abuse of the health care system, caregivers need and deserve a break. Many family caregivers are balancing other work and other family obligations in addition to caring for someone 24/7/365. Official respite services aren’t always available, are often unaffordable, and can’t always meet a patient’s needs—so it’s understandable that some caregivers have to resort to the pop drop.