The report is a product of the VA/HSR 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
The literature addressing intervention strategies for older adults presenting to EDs is diverse. Case management and discharge planning were commonly used, and one-half of the studies employed more than one intervention strategy. Overall, results indicate mixed effects of ED intervention strategies on select clinical and utilization outcomes. The small number of studies using any single intervention strategy makes it difficult to draw definitive conclusions because of imprecise estimates of effect and variability in study populations, intervention strategies, and intervention components. Additional findings include:

• ED interventions did not show a reduction in mortality, but no study identified mortality as a primary outcome. There were few deaths in the included studies, so this finding was based on a low number of events, and confidence intervals do not exclude an important effect.
• There were no effects overall of ED interventions on hospitalization at the index visit (very low strength of evidence or SOE), subsequent hospitalizations (low SOE), or ED readmission (high SOE).
• Studies with the greatest effects on clinical and healthcare use outcomes employed more comprehensive interventions, but this pattern was not consistent across all effective interventions:
  
  • Multi-strategy interventions, defined as those using more than one intervention strategy (e.g., discharge planning, case management, medication management) may be associated with less decline in functional independence.
  • More intensive interventions, as indicated by the presence of three key intervention components (i.e., assessment, referral plus follow-up and contact both pre- and post-ED discharge) may be associated with less decline in functional independence and decreased hospitalization after the ED index visit and/or ED readmissions.
  • Single-contact interventions, whether delivered in the ED or after discharge, do not improve outcomes.

Future Research
There are several gaps in the existing literature. Few studies actively recruited Veterans or populations representing diverse racial and ethnic groups. Further, the literature often lacks complete descriptions of intervention strategies and components, and few studies examined optimal dose of intervention strategies (i.e., number of contacts and duration of intervention) or optimal timing and setting (both within the ED and after discharge). Although one-half of studies targeted high-risk patients, few examined which subpopulations of older adults benefit from emergency department interventions.

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.**

Reference
Hughes JM, Freiermuth C, Williams JW Jr, Ragsdale L, Eucker S, Goldstein KM, Rodriguez R, Fulton J, Hastings N, Shepherd-Banigan M, Ramos K, Alishahi Tabriz A, Gordon AM, Gierisch JM, Kosinski A, McDuffie J, Van Noord M. Emergency Department Strategies for Older Adults. VA ESP Project #09-009; 2018.

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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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