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Abstract
Objective High utilisation of emergency department (ED) among the elderly is of worldwide concern. This study aims to review the effectiveness of interventions targeting the elderly population in reducing ED utilisation.
Methods Major biomedical databases were searched for relevant studies. Qualitative approach was applied to derive common themes in the myriad interventions and to critically assess the variations influencing interventions’ effectiveness. Quality of studies was appraised using the Effective Public Health Practice Project (EPPHP) tool.
Results 36 studies were included. Nine of 16 community-based interventions reported significant reductions in ED utilisation. Five of 20 hospital-based interventions proved effective while another four demonstrated failure. Seven key elements were identified. Ten of 14 interventions associated with significant reduction on ED use integrated at least three of the seven elements. All four interventions with significant negative results lacked five or more of the seven elements. Some key elements including multidisciplinary team, integrated primary care and social care often existed in effective interventions, while were absent in all significantly ineffective ones.
Conclusions The investigated interventions have mixed effectiveness. Our findings suggest the hospital-based interventions have relatively poorer effects, and should be better connected to the community-based strategies. Interventions seem to achieve the most success with integration of multi-layered elements, especially when incorporating key elements such as a nurse-led multidisciplinary team, integrated social care, and strong linkages to the longer-term primary and community care. Notwithstanding limitations in generalising the findings, this review builds on the growing body of evidence in this particular area.
- emergency department
- aged
- effectiveness
- emergency care systems
- epidemiology
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Introduction
Increasing emergency department (ED) utilisation threatens EDs’ role in timely responding to patients’ acute care needs. ED overload has incurred constant complaints and public concerns, as it could cause delayed access to time-sensitive treatment, patient dissatisfaction, susceptibility to hospital-acquired complications, and even failure of the entire hospital and health system.1
Research suggests that the elderly population is a major contributor to ED utilisation.2 ,3 This population is characterised by chronic conditions susceptible to exacerbations, atypical symptoms and multiple comorbidities, cognitive and functional impairment, and related social problems,3 ,4 making them highly dependent on EDs and with substantially more needs than other patients. Compared with their younger counterparts, older adults are more likely to present to EDs, to consume staff time and emergency resources, and to develop subsequent adverse events after discharge.2 Thus they become a natural target for interventions and can most benefit if well-established interventions are in place.
With the population ageing worldwide, it is imperative to develop appropriate interventions targeted at the ED use by the elderly. Although a variety of interventions have been initiated across countries, their effectiveness remains unclear. This review, therefore, aims to appraise their effectiveness in reducing ED utilisation and identify core characteristics shared by successful intervention models.
Methods
Search strategy
This review examined the literature regarding the effectiveness of geriatric interventions aimed at reducing ED utilisation. Ethics approval was not required because this study did not involve the use of human subjects or medical records.
Major biomedical databases including PubMed, CINAHL, EMBASE, Web of Science and EBSCO (inception to January 2014) were searched, using the following key terms: “emergency department” or “emergency room” or “ED” or “emergency service” or “emergency utilization” or “emergency use” or “emergency visit” or “emergency attendance” or “emergency presentation” or “emergency demand” AND “elderly” or “aged” or “older” or “geriatric” or “senior” AND “intervention” or “assessment” or “evaluation” or “trial” or “effect” or “impact” or “solution”. Language of articles was limited to English. Reference lists of identified articles were manually searched for additional literature.
Inclusion and exclusion criteria
Studies were included if they: (a) focused on the effectiveness evaluation of strategies targeting the elderly population to reduce ED utilisation; (b) reported a measure of ED utilisation as study outcome; (c) were original research, either an experimental study or an observational study.
Studies were excluded if they: (a) did not provide a description of intervention; (b) were investigating interventions limited to patients with particular medical diagnoses; (c) used non-elderly population as the study sample, unless the results for the younger subjects and the older subjects were presented separately; (d) reported only on patients’ or health providers’ subjective perceptions; (e) failed to report sufficient quantitative data to measure the outcome of interest; (f) had no control or comparison group.
Data collection and processing
We examined all articles initially retrieved to identify relevant ones. Articles were discarded for further consideration after screening the titles and abstracts, if they clearly did not address the concern of our review or violated any selection criteria. The remaining articles were retrieved for full texts, and reviewed to determine which could be included.
Each relevant study was extracted for the information including year, country, study design, sample size, study population, intervention characteristics, duration, outcome measure, and effects.
Data analysis
A qualitative approach was used for this review, owing to the heterogeneity of study designs, interventions and outcome measures that precluded meta-analysis. Core elements of interventions were derived in a similar approach to Sinha et al.5 One author (LF) reviewed each study and listed all characteristic elements included in the studied interventions. Individual studies were further examined to determine whether they were reporting different terms for the same elements or the same terms for different elements, to further combine or separate the element groups in the initial list. A set of core elements was ultimately summarised. After identification of all core elements, each individual intervention was again reviewed, determined as adhering or not to a particular element. Above steps were checked by a second author (WL), an ED Senior Staff Specialist, and discrepancies were resolved by consensus.
Results of adherence patterns were then used to draw inferences about the specific elements that might be associated with the intervention effectiveness. All other intervention-related characteristics such as intervention setting and duration were also narratively synthesised for comparison across studies, to highlight common themes that emerged.
Quality assessment
Methodological quality of the studies was appraised using a standardised quality assessment tool developed by the Effective Public Health Practice Project (EPHPP).6 Six methodological components including selection bias, study design, confounders, blinding, data collection methods, and withdrawals and drop-outs, will be considered when determining the global rating of each study on a three-point scale (strong, moderate or weak). Two researchers (LF, JZ) independently assessed the quality of included studies and resolved any disagreements through a consensus discussion with a third reviewer (X-YH).
Results
The initial search yielded 1359 publications and 134 of them were considered as potentially relevant and underwent full-text review against selection criteria, resulting in a total of 36 studies included in the review (figure 1).
Flowchart of included/excluded studies.
Of these 36 studies, 15 were conducted in the US, nine in Australia, eight in Canada, and one in each of the following countries: the UK, France, Italy and Singapore, with their sample size ranging from 41 to 2139. Key characteristics of these studies are shown in online supplementary table S1,7–42 with all studies being organised around one of two categories according to the primary setting of their investigated interventions, namely, the community setting (home or community or community-based outpatient) and the hospital setting (ED or inpatient).
Based on the qualitative analytic approach, seven core elements integral to the studied interventions were identified and are listed in table 1. Adherence of each intervention to the seven elements is also summarised in table 1. Three interventions were not adherent to any of these seven elements.13 ,23 ,24 They each used a unique model (ie, telemonitoring, ‘4-h target’, and an ED aged care pharmacist, respectively) and were thus analysed separately.
Characteristic elements common to studied interventions and adherence of interventions to the seven elements7–42
Effectiveness of community-based interventions
Of 16 studies examining community-based geriatric interventions, over half of them (9 out of 16) reported significant reductions in ED utilisation with interventions,7 ,11 ,12 ,14 ,16 ,18–20 ,22 among which five were randomised controlled trials (RCTs), one controlled clinical trial, two PPs, and one cross-sectional study. These nine interventions had an average duration of 12 months, with only one lasting less than 6 months. All these interventions used multidisciplinary team and gerontological expertise (Element 1). Other elements were also very often incorporated, used by half or over of the interventions, including: integrated and enhanced primary care (Element 2),7 ,11 ,14 ,16 ,18–20 integrated social and medical care (Element 3),7 ,12 ,16 ,22 care planning and management (Element 5),7 ,11 ,12 ,22 and follow up and regular group visits (Element 7).16 ,18 ,19 ,22 Risk screening and geriatric assessment (Element 4) and discharge planning and referral coordination (Element 6) were relatively less applied, by two interventions11 ,22 and one intervention,22 respectively.
Six other community-based interventions (five RCTs and one PP), although not statistically significant, also resulted in a diminished likelihood of ED usage in intervention groups.8–10 ,15 ,17 ,21 These interventions, with similarly long durations of no less than 7 months, also featured multiple key elements. Five of them were multidisciplinary-based,8 ,10 ,15 ,17 ,21 four conducted screening and assessment,9 ,10 ,15 ,21 four had care management,8–10 ,21 three involved follow up visits,9 ,17 ,21 three integrated social care,8 ,15 ,21 two linked to primary care,15 ,17 and one performed discharge planning.21 Only one RCT, studying telemonitoring within home for symptom assessment and treatment initiation, reported an increase in ED attendances, but also failed to demonstrate significance.13
Effectiveness of hospital-based interventions
Twenty studies explored the effectiveness of hospital-based interventions. Of them, only five studies demonstrated statistical significance in lowering ED use or ED length of stay (LOS).27 ,31 ,32 ,36 ,37 None of them used RCTs. Two of the five interventions featured multidisciplinary team and care planning,36 ,37 and another two interventions included follow-up visits.31 ,32 However, unlike community-based interventions, these hospital-based strategies were most characterised by risk screening and geriatric assessment for the purpose of identifying potential risk factors and unresolved problems,27 ,32 ,36 ,37 and discharge planning and referral coordination.31 ,32 Most of the interventions were relatively long-term, with only two being shorter than 6 months. Another study evaluated a ‘four-hour target’ to dispose ED patients (although not specifically to reduce ED use by geriatric patients), and reported the outcome of ED return visit as a safety check on whether the policy would create any harm or incomplete examinations.24 Although the policy resulted in an insignificant decrease in ED return visits among elders, it achieved a shortened LOS during patients’ initial visit.
Two studies, however, found paradoxically higher ED utilisation,23 ,26 and another two revealed a strong trend towards higher use.25 ,34 Three of them were RCTs and one case-control study. All four interventions employed a unidisciplinary approach comprising an ED-based specialist pharmacist23 or a nurse,25 ,26 ,34 and none integrated primary care or social care. Only one intervention had phone calls and home visits to follow up but within limited periods of time.26 Three of these four had a short duration of no more than 1 month,23 ,25 ,34 with only one continuing through 10 months.26
Another seven studies showed no statistical significance of the intervention, three of which documented increases in ED use,28 ,40 ,41 and four reported reductions.30 ,33 ,38 ,39 These interventions involved: case finding and discharge planning, with short-term community liaison but no interprofessional input;30 ,33 ,39 ,40 care plan and no or limited follow up,28 ,33 ,38 and nurse-led disease management model of transitional care.41 Three other RCT studies tested the ED visit rate at a shorter and a longer time of investigation, and found some contradictions in results at different periods.29 ,35 ,42 Koehler et al35 reported the intervention significantly decreased ED use at 30 days but failed to demonstrate significance at 60 days. Mion et al29 documented a strong trend towards increased ED use at 30 days, although this trend disappeared at 120 days, changing to insignificant reductions. Legrain et al42 found a same trend as Mion et al's, with an insignificant increase at 3 months and an insignificant decrease at 6 months.
Overall, table 1 demonstrates that 10 of the 14 interventions associated with significant reduction on ED utilisation integrated at least three of the seven characteristic elements, and only one incorporated less than two elements. However, all of the four interventions with significant negative results were lacking five or more of the seven elements. “Multidisciplinary team and gerontological expertise”, “integrated and enhanced primary care”, and “integrated social and medical care” existed in 11 (79%), 7 (50%) and 4 (29%) interventions with positive results; while they were absent in all four studies with negative results. “Risk screening and geriatric assessment” (or “care planning and management”, or “follow up and regular group visits”) was incorporated into 6 (43%) interventions with positive results but only 1 (25%) intervention with negative results. Only “discharge planning and referral coordination” was more frequently used by interventions with negative results (2 of 4) than those with positive results (3 of 14).
Overall quality of the included studies based on the EPHPP tool is presented in online supplementary table S1, and an analysis of the individual items is shown in figure 2. Five studies were available only as abstracts, which limited assessment of quality and were thus not appraised against the EPHPP tool.16 ,22 ,25 ,26 ,30 Of the 31 studies assessed, four were appraised as strong,7 ,12 ,13 ,39 17 were rated as moderate,8–10 ,15 ,17 ,19–21 ,23 ,24 ,28 ,29 ,31 ,34 ,35 ,38 ,42 and 10 were of weak quality.11 ,13 ,18 ,27 ,32 ,33 ,36 ,37 ,40 ,41 Blinding, Selection bias, Confounders, and Data Collection Methods are the most problematic methodological components that result in the weak and low quality of these studies.
Frequency of the six components of the Effective Public Health Practice Project (EPHPP) tool and Global ratings of studies.
Discussion
To our knowledge, this is the first critical review of effectiveness of the myriad interventions targeting the elderly population to reduce ED visits. Several general themes have emerged that may improve our understanding in this particular area.
When grouped according to their primary setting of practice, a larger proportion of community-based interventions demonstrated significant improvement in the ED outcome, as compared with hospital-based interventions. Somewhat paradoxically, some hospital-based interventions worsened the outcome. The superiority of community-based interventions over hospital-based ones is consistent with the finding from some previous literature.3 The variance in their effectiveness of community versus hospital based interventions may be explained by their different approaches. Community-based interventions usually have a focus of preventing the older residents from illnesses or functional decline, while hospital-based interventions focus on rehabilitation and follow-up of the already sick elders. These hospital-based patients tend to suffer more hospital-acquired complications and have higher level of health deterioration, and may often require ED return visits to stabilise their ill conditions. Besides, the location of the interventions may promote or impede their ability to incorporate primary care and social care needed to respond to the distinctive care needs of elders. The community-based interventions better ensure the care continuum for patients for a longer time period.
We have identified seven key elements integrated in the intervention models and examined the effects of the presence or absence of a particular element in influencing the interventions’ effectiveness. Some core principles are proposed. For example, previous research showed that nurses represent an undeniably important force in driving and coordinating appropriate care for older patients.4 However, a number of nurse-led unidisciplinary interventions have failed to show a significant reduction in ED utilisation, while multidisciplinary ones have been more successful.25 ,26 ,29 ,30 ,34 Therefore, while nurses remain a critical component, we would recommend a multidisciplinary team with gerontological expertise to achieve the greatest potential for improvement.7 ,11 ,12 The multidisciplinary team approach is one element that was found in most of the successful interventions while absent in all statistically ineffective ones. This finding also applies to two other elements (integrated and enhanced primary care, and integrated social and medical care). This may indicate the potential importance of incorporating into interventions a multidisciplinary team with gerontological expertise, enhanced primary care, and integrated social care.
Another core principle is risk screening and geriatric assessment to identify the underlying and undetected health problems, facilitating appropriate care planning and management in a timely and accurate manner. Regular follow-up visits are especially necessary to ensure the pre-determined care plans are strictly followed and to allow further revision or reinforcement of the plans, so as to ensure patients’ continuity of care and to meet their changing care needs. Such follow-up intervention is recommended to last for an appropriately long period to increase its possibility of working.26 In addition, although both pros and cons of an element shall be considered, we generally realise that interventions incorporating multiple elements are more likely to succeed.
Besides the intervention's location and component, its duration is also important. Longer-term interventions seem to have a higher possibility of achieving success. The overall lack of effect of short-term interventions might be attributable to the period being too short to demonstrate significance and the failure in maintaining care continuum.29 ,42 However, one hospital-based intervention has shown an inconsistent finding, as it is effective in first 30 days but the effect wanes over a longer period.35 A possible explanation is, the model has taken advantage of the hospital staff's ability to improve short-term ED outcome but unfortunately, failed to refer these patients to longer-term transitional and community care to extend the effectiveness.
Limitations
Our study has a number of limitations as well. First, the risk of publication bias would make our results biased too. Second, we have excluded all non-English studies, which might also include important findings. Third, many included studies are of moderate or weak quality, suggesting weakness in attributing any reported effects to the actual interventions. Even the findings from high-quality RCTs require caution regarding their translatability and applicability in practice, given that those well-controlled events in a trial may not be achieved in real life. Fourth, the majority of the interventions were implemented in a single centre or country, hindering generalisability and applicability to an extended population and other settings. Whether it was the specific intervention or the combination of it with the external local contextual factors that was responsible for the effects is difficult to know, as identical interventions could have different effectiveness in different practice settings. However, our identification of the core elements of successful interventions may mean particular elements can transcend different locations. Last, the heterogeneity in quality of studies, trial design, interventions, settings, study period and outcome measures made it difficult to combine, compare, and interpret the results across studies. It is challenging to generalise the results and essentially impossible to draw robust and definite conclusions from the findings of this review.
Conclusions
Studies investigating interventions targeting the elderly population have mixed results regarding their effectiveness in reducing ED utilisation. A qualitative appraisal of the nature and effect of these interventions helps to extract a number of factors to be considered when formulating an effective geriatric intervention. Our findings suggest the hospital-based interventions have relatively poorer effects, which need to be designed in a more thorough manner and be better connected to the community-based strategies. Interventions seem to achieve the most success with integration of multi-layered elements, especially when key elements such as a nurse-led multidisciplinary team, integrated social care, and strong linkages to the longer-term primary and community care services are incorporated. However, given that methodological issues have limited our ability to generalise the results and to make definite recommendations, findings from the review need to be interpreted and applied carefully by ED clinicians and policy-makers, warranting consideration of the organisation priority in each practice setting, appropriate adjustment of interventions, and local evaluation to monitor intervention outcomes. Future studies should attempt to use robust high-quality design to reduce confounding and thus to understand fundamental influential factors that affect the effectiveness. Interventions should be precisely defined in all studies. Outcome reporting needs to be standardised to facilitate comparisons across studies, through reporting the same type of ED visit and reporting the outcome consistently as either “the total number of ED visits” or “the number of ED visits per user”. Notwithstanding all limitations, our efforts in carrying out this review build on the growing body of evidence in this important area.
Acknowledgments
The authors acknowledge the support from the School of Public Health and Social Work at Queensland University of Technology and the QEMRF (Queensland Emergency Medicine Research Foundation) funded research project (Project ID: QEMRF-PORJ-2009-014, Title: A Comprehensive Evaluation of a Hospital in Nursing Home Program in Three Queensland Hospitals).
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online table
Footnotes
Contributors LF performed the literature review and drafted the manuscript. In their capacity of supervisors and mentors, X-YH, WL, JZ and JS initiated the study conception, assisted with the review process and contributed to the final draft.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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