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|Issue 146||September 2018|
The report is a product of the VA/HSR&D Evidence Synthesis Program.
Systematic Review: Emergency Department Interventions for Older Adults
Older adults, particularly those 75 years of age and older, visit the emergency department (ED) with nearly twice the frequency of their younger counterparts. Within VA, older Veterans account for 40% of the 2.4 million annual ED visits. This figure will continue to rise as the number of older Veterans is expected to increase significantly over the next decade. Moreover, older adults presenting to the ED can experience challenges that make care more difficult, such as multiple morbidities, polypharmacy, atypical symptoms, functional disabilities, impaired cognition, and reduced social support. To address these challenges, a range of interventions have been evaluated in prior studies, including care delivery, case management, and transitional care or discharge planning. Systems-level attention to these challenges is also evident in the 2014 publication of the Geriatric Emergency Department Guidelines. These collaborative guidelines provide a template for staffing, equipment, education, policies and procedures, follow-up care, and performance-improvement measures, but do not include evidence-based recommendations on specific ED interventions.
At the request of the VA Offices of Geriatrics and Extended Care Operations and Emergency Medicine, this systematic review sought to fill gaps in the literature by synthesizing the evidence on ED interventions for clinical outcomes, including functional status, quality of life, hospital admission, and ED readmission. To this end, investigators with VA's Evidence-based Synthesis Coordinating Center in Durham, NC reviewed the literature including MEDLINE®, Embase, and CINAHL through December 4, 2017; they also searched ClinicalTrials.gov. Eligible studies evaluated case management, discharge planning, medication management, and/or geriatric guideline-based intervention strategies; studies focused on single conditions (e.g., geriatric falls, stroke) were excluded. After reviewing nearly 2,000 articles, 17 articles describing 15 unique studies (9 randomized studies and 6 non-randomized) were used to answer the key question: How effective are emergency department (ED) interventions in improving clinical, patient experience, and utilization outcomes in older adults (age >65)?
Summary of Review
Future research should take a more comprehensive view of the multilevel factors (i.e., individual, community, and systems levels) that influence ED use and resulting clinical and utilization outcomes, while also adhering to more thorough reporting of intervention structure and characteristics. Adaptive designs might help achieve a balance between broad, population-oriented interventions and those that are patient-centered and tailored to meet the needs of high-risk subgroups. Innovative evaluation designs, including factorial and hybrid designs respectively, can allow researchers to isolate intervention components in order to assess individual and interactive effects of intervention strategies — and to evaluate interventions in real-world settings. Future research also should address current limitations in outcome measures, including the selection of measures that are responsive to change and that apply to older adults with a range of medical conditions rather than a specific diagnosis.
The VA healthcare system is an ideal setting to pursue additional research in geriatric emergency medicine given its integrated structure, high proportion of complex patients, and continuum of available geriatrics services. Finally, there is substantial opportunity to engage patients, providers, and other stakeholders in this research, and to use the 2014 Geriatric Emergency Department Guidelines to inform future studies.
**A cyberseminar session titled "ESP Report: Emergency Department Interventions for Older Adults" will be held on Thursday, December 20, 2018 from 12:00pm to 1:00pm (ET). Register for this session.**
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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.
This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.
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