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McHugh MC, Muschong KM, Bradley SM, Lo AX. Perspectives from persons living with dementia and their caregivers on emergency department visits, care transitions, and outpatient follow-up: A qualitative study. Acad Emerg Med 2024. [PMID: 38590030 DOI: 10.1111/acem.14898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Persons living with dementia (PLWD) experience frequent and costly emergency department (ED) visits, with poor outcomes attributed to suboptimal care and postdischarge care transitions. Yet, patient-centered data on ED care experiences and postdischarge needs are lacking. The objective of this study was to examine the facilitators and barriers to successful ED care and care transitions after discharge, according to PLWD and their caregivers. METHODS We conducted a qualitative study involving ED patients ages 65 and older with confirmed or suspected dementia and their caregivers. The semistructured interview protocol followed the National Quality Forum's ED Transitions of Care Framework and addressed ED care, care transitions, and outpatient follow-up care. Interviews were conducted during an ED visit at an urban, academic ED. Traditional thematic analysis was used to identify themes. RESULTS We interviewed 11 patients and 19 caregivers. Caregivers were more forthcoming than patients about facilitators and challenges experienced. Characteristics of the patients' condition (e.g., resistance to care, forgetfulness), the availability of family resources (e.g., caregiver availability, primary care access), and system-level factors (e.g., availability of timely appointments, hospital policies tailored to persons with dementia) served as facilitators and barriers to successful care. Some resources that would ameliorate care transition barriers could be easily provided in the ED, for example, offering clear discharge instructions and care coordination services and improving patient communication regarding disposition timeline. Other interventions would require investment from other parts of the health care system (e.g., respite for caregivers, broader insurance coverage). CONCLUSIONS ED care and care transitions for PLWD are suboptimal, and patient-level factors may exacerbate existing system-level deficiencies. Insight from patients and their caregivers may inform the development of ED interventions to design specialized care for this patient population. This qualitative study also demonstrated the feasibility of conducting ED-based studies on PLWD during their ED visit.
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Affiliation(s)
- Megan C McHugh
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kayla M Muschong
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sara M Bradley
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander X Lo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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2
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Serina PT, Xu C, Baird J, Wang HE, Donnelly JP, Amanullah S, Lo AX. Emergency department resource utilization among nursing home residents, a National Cross-Sectional Study. Am J Emerg Med 2024; 78:76-80. [PMID: 38241773 DOI: 10.1016/j.ajem.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVES Persons 65 years and older (older persons), particularly residents of nursing homes (NHs), disproportionately access the emergency department (ED) and utilize more medical resources. The goal of this study is to provide a contemporary description of healthcare utilization patterns and disposition decisions for United States (US) NH residents presenting to EDs. METHODS Older persons presenting to EDs in the US were identified in the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2017, 2018 and 2019 datasets. We examined demographic, clinical, and resource use characteristics and outcomes. After survey weighting, we compared the frequency of different imaging, medications, clinical interventions, and outcomes in the ED between NH residents and those residing outside NHs. RESULTS From 2017 to 2019, older persons made 24,441,285 annual visits to the ED, comprising 17.5% of all visits. Among these, 1,579,916 visits (6.5%) were by NH residents. Compared with non-NH residents, NH residents were older (mean age: 81.2 [95%CI 81.5-82.9] vs 76.1 [95%CI 75.8-76.4]), underwent more imaging (82.8% [95%CI 79.5-86.1] vs 71.6% [95%CI 69.9-73.3]), were administered fewer potentially inappropriate medications (PIMs) in the ED or upon discharge (9.5% [95%CI 6.2-2.7] vs 17.1% [95%CI 15.8-18.4]), and had a higher proportion of visits resulting in hospital admission (44.1% [95%CI 38.2-49.9] vs 26.0% [95%CI 23.3, 28.7]). CONCLUSIONS Older NH residents presenting to the ED use more resources and are more likely to be hospitalized compared to older persons residing outside NHs. The resource-intensive nature of these visits highlights the importance of targeted, multi-disciplinary interventions that optimize ED care for this population.
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Affiliation(s)
- Peter T Serina
- Brown University, Center for Gerontology and Healthcare Research, Providence, RI, USA; Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, RI, USA.
| | - Chuyun Xu
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, RI, USA
| | - Janette Baird
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, RI, USA
| | - Henry E Wang
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, OH, USA
| | - John P Donnelly
- University of Michigan Medical School, Department of Learning Health Sciences, Ann Arbor, MI, USA; VA HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA; VA QUERI Center for Evaluation and Implementation Resources, Ann Arbor, MI, USA
| | - Siraj Amanullah
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, RI, USA
| | - Alexander X Lo
- Northwestern Medicine, Department of Emergency Medicine, Chicago, IL, USA
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3
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Wolf LA, Lo AX, Serina P, Chary A, Sri‐On J, Shankar K, Sano E, Liu SW. Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review. J Am Coll Emerg Physicians Open 2024; 5:e13084. [PMID: 38162531 PMCID: PMC10755799 DOI: 10.1002/emp2.13084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024] Open
Abstract
Objective Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years. Methods A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting. Results A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making. Conclusion The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionals on patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.
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Affiliation(s)
- Lisa A. Wolf
- Emergency Nurses AssociationSchaumburgIllinoisUSA
| | - Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Peter Serina
- Department of Emergency MedicineBrown UniversityProvidenceRhode IslandUSA
| | - Anita Chary
- Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
| | - Jiraporn Sri‐On
- Department of Emergency MedicineVajira HospitalBangkokThailand
| | - Kalpana Shankar
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Ellen Sano
- Department of Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Shan W. Liu
- Department of Emergency MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Lo AX, Wadley VG, Brown CJ, Long DL, Crowe M, Howard VJ, Kennedy RE. Life-Space Mobility: Normative Values From a National Cohort of U.S. Older Adults. J Gerontol A Biol Sci Med Sci 2024; 79:glad176. [PMID: 37480583 PMCID: PMC10803118 DOI: 10.1093/gerona/glad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Life-space mobility, which measures the distance, frequency, and independence achieved as individuals move through their community, is one of the most important contributors to healthy aging. The University of Alabama at Birmingham Life-Space Assessment (LSA) is the most commonly used measure of life-space mobility in older adults, yet U.S. national norms for LSA have not previously been reported. This study reports such norms based on age and sex among community-dwelling older adults. METHODS A cross-sectional analysis using data from the national REasons for Geographic and Racial Disparities in Stroke cohort study. LSA data were available for 10 118 Black and White participants over age 50, which were grouped by age (in 5-year increments) and sex, weighted for the U.S. national population. Correlations were calculated between LSA and measures of functional and cognitive impairment and physical performance. RESULTS The weighted mean LSA ranged from 102.9 for 50-54-year-old males to 69.5 for males aged 85 and older, and from 102.1 for 50-54-year-old females to 60.1 for females aged 85 and older. LSA was strongly correlated with measures of timed walking, activities of daily living, cognition, depressive symptoms, and quality of life (all p < .001). CONCLUSIONS We report U.S. national norms for LSA among community-dwelling Black and White older adults. These norms can serve as a reference tool for determining if clinical and research samples have greater or lesser life-space mobility than typical older adults in the United States for their age and sex.
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Affiliation(s)
- Alexander X Lo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Virginia G Wadley
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cynthia J Brown
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - D Leann Long
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael Crowe
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Richard E Kennedy
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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5
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Rundle AG, Crowe RP, Wang HE, Beard JR, Lo AX. A National Study on the Comparative Burden of Pedestrian Injuries from Falls Relative to Pedestrian Injuries from Motor Vehicle Collisions. J Urban Health 2024; 101:181-192. [PMID: 38236430 PMCID: PMC10897068 DOI: 10.1007/s11524-023-00815-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 01/19/2024]
Abstract
Pedestrian injuries from falls are an understudied cause of morbidity. Here, we compare the burden of pedestrian injuries from falls occurring on streets and sidewalks with that from motor vehicle collisions. Data on injurious falls on streets and sidewalks, and pedestrian-motor vehicle collisions, to which Emergency Medical Services responded, along with pedestrian and incident characteristics, were identified in the 2019 National Emergency Medical Services Information System database. In total, 118,520 injurious pedestrian falls and 33,915 pedestrians-motor vehicle collisions were identified, with 89% of the incidents occurring in urban areas. Thirty-two percent of pedestrians struck by motor vehicles were coded as Emergent or Critical by Emergency Medical Services, while 19% of pedestrians injured by falls were similarly coded. However, the number of pedestrians whose acuity was coded as Emergent or Critical was 2.1 times as high for injurious falls as compared with pedestrians-motor vehicle collisions. This ratio was 3.9 for individuals 50 years and older and 6.1 for those 65 years and older. In conclusion, there has been substantial and appropriate policy attention given to preventing pedestrian injuries from motor vehicles, but disproportionately little to pedestrian falls. However, the population burden of injurious pedestrian falls is significantly greater and justifies an increased focus on outdoor falls prevention, in addition to urban design, policy, and built environment interventions to reduce injurious falls on streets and sidewalks, than currently exists across the USA.
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Affiliation(s)
- Andrew G Rundle
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Henry E Wang
- Department of Emergency Medicine, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - John R Beard
- Robert N. Butler Columbia Aging Center, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Alexander X Lo
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA.
- Center for Health Services & Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Rundle AG, Crowe RP, Wang HE, Lo AX. Correction: A methodology for the public health surveillance and epidemiologic analysis of outdoor falls that require an emergency medical services response. Inj Epidemiol 2023; 10:56. [PMID: 37924138 PMCID: PMC10625182 DOI: 10.1186/s40621-023-00469-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2023] Open
Affiliation(s)
- Andrew G Rundle
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, 10032, USA.
| | | | - Henry E Wang
- Department of Emergency Medicine, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Alexander X Lo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Health Services & Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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7
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Rundle AG, Crowe RP, Wang HE, Beard JR, Lo AX. A National Study on the Comparative Burden of Pedestrian Injuries from Falls Relative to Pedestrian Injuries from Motor Vehicle Collisions. Res Sq 2023:rs.3.rs-3218781. [PMID: 37609339 PMCID: PMC10441469 DOI: 10.21203/rs.3.rs-3218781/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Pedestrian injuries from falls are an understudied cause of morbidity. Here we compare the burden of pedestrian injuries from falls occurring on streets and sidewalks with that from motor vehicle collisions. Data on injurious falls on streets and sidewalks, and pedestrian-motor vehicle collisions, to which Emergency Medical Services responded, along with pedestrian and incident characteristics, were identified in the 2019 National Emergency Medical Services Information System database. In total, 129,343 injurious falls and 33,910 pedestrians-motor vehicle collisions were identified, with 89% of the incidents occurring in urban areas. Thirty two percent of pedestrians struck by motor vehicles were coded as Emergent or Critical by Emergency Medical Services, while 20% of pedestrians injured by falls were similarly coded. However, the number of pedestrians whose acuity was coded as Emergent or Critical was 2.33 times as high for injurious falls as compared with pedestrians-motor vehicle collisions. This ratio was nearly double at 4.3 for individuals 50 years and older, and almost triple at 6.5 for those 65 years and older. In conclusion, there has been substantial and appropriate policy attention given to preventing pedestrian injuries from motor vehicles, but disproportionately little to pedestrian falls. However, the population burden of injurious pedestrian falls is significantly greater and justifies an increased focus on outdoor falls prevention, in addition to urban design, policy and built environment interventions to reduce injurious falls on streets and sidewalks, than currently exists across the U.S.
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Affiliation(s)
| | | | | | - John R Beard
- Columbia University Mailman School of Public Health
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8
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Lee S, Cavalier FR, Hayes JM, Doering M, Lo AX, Khoujah D, Howard MA, de Wit K, Liu SW. Delirium, confusion, or altered mental status as a risk for abnormal head computed tomogram findings in older adults in the emergency department: A Geriatric Emergency Department Guidelines 2.0 systematic review and meta-analysis. Am J Emerg Med 2023; 71:190-194. [PMID: 37423026 DOI: 10.1016/j.ajem.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/17/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Altered mental status (including delirium) is a common presentations among older adults to the emergency department (ED). We aimed to report the association between altered mental status in older ED patients and acute abnormal findings on head computed tomogram (CT). METHODS A systematic review was conducted using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8th, 2021. We included citations if they described patients aged 65 years or older who received head imaging at the time of ED assessment, and reported whether patients had delirium, confusion, or altered mental status. Screening, data extraction, and bias assessment were performed in duplicate. We estimated the odds ratios (OR) for abnormal neuroimaging in patients with altered mental status. RESULTS The search strategy identified 3031 unique citations, of which two studies reporting on 909 patients with delirium, confusion or altered mental status were included. No identified study formally assessed for delirium. The OR for abnormal head CT findings in patients with delirium, confusion or altered mental status was 0.35 (95% CI 0.031 to 3.97) compared to patients without delirium, confusion or altered mental status. CONCLUSION We did not find a statistically significant association between delirium, confusion or altered mental status and abnormal head CT findings in older ED patients.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, United States of America.
| | - Faithe R Cavalier
- College of Liberal Arts and Sciences, University of Iowa, Iowa City, IA, United States of America
| | - Jane M Hayes
- Harvard Affiliated Emergency Medicine Residency, Mass General Brigham, Boston, MA, United States of America
| | - Michelle Doering
- Bernard Becker Medical Library, Washington University School of Medicine in St. Louis, St. Louis, MO, United States of America
| | - Alexander X Lo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Danya Khoujah
- Department of Emergency Medicine, Tampa AdventHealth, FL, United States of America; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, United States of America
| | - Kerstin de Wit
- Department of Emergency Medicine, Queens University, Kingston, Ontario, Canada; Division of Emergency Medicine, Department of Medicine,McMaster University, Hamilton, Ontario, Canada
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States of America
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Lo AX, Kennedy M. It's time to mobilize: Moving mobility interventions for delirium from inpatient units to the emergency department. J Am Coll Emerg Physicians Open 2023; 4:e12900. [PMID: 36776215 PMCID: PMC9902676 DOI: 10.1002/emp2.12900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 02/10/2023] Open
Affiliation(s)
- Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA,Center for Health Services & Outcomes ResearchNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA,Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
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10
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Rundle AG, Crowe RP, Wang HE, Lo AX. A methodology for the public health surveillance and epidemiologic analysis of outdoor falls that require an emergency medical services response. Inj Epidemiol 2023; 10:4. [PMID: 36635714 PMCID: PMC9835276 DOI: 10.1186/s40621-023-00414-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Falls are a common cause of injury with significantly associated medical costs yet public health surveillance of injuries from falls is underdeveloped. In addition, the epidemiologic understanding of outdoor falls, which have been reported to account for 47% of all injurious falls, is scant. Here we present methods to use emergency medical services (EMS) data as a public health surveillance tool for fall injuries, including those that occur secondary to syncope and heat illness, with a focus on the scope and epidemiology of outdoor fall injuries. METHODS Using the 2019 National Emergency Medical Services Information System (NEMSIS) data, we developed an approach to identify EMS encounters for fall injuries, syncope and heat illness. NEMSIS variables used in our algorithm included the EMS respondent's impression of the encounter, the reported major symptoms and the cause of injury. With these data we identified injuries from falls and, using the NEMSIS data on the location of the encounter, we identified fall injuries as occurring indoors or outdoors. We present the descriptive epidemiology of the identified patients. RESULTS There were 1,854,909 injuries from falls that required an EMS response identified in the NEMSIS data, with 4% of those injuries secondary to episodes of syncope (n = 73,126) and heat illness. Sufficient data were available from 94% of injurious falls that they could be assigned to indoor or outdoor locations, with 9% of these fall injuries occurring outdoors. Among fall injuries identified as occurring outdoors, 85% occurred on streets and sidewalks. Patient age was the primary sociodemographic characteristic that varied by location of the injurious fall. Sixty-six percent of fall injuries that occurred indoors were among those age 65 years or older, while this figure was 34% for fall injuries occurring outdoors on a street or sidewalk. CONCLUSION The occurrence of outdoor fall injuries identified in the NEMSIS data were substantially lower than reported in other data sets. However, numerically fall injuries occurring outdoors represent a substantial public health burden. The strengths and weaknesses of using this approach for routine public health surveillance of injuries from falls, syncope and heat illness are discussed.
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Affiliation(s)
- Andrew G Rundle
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, 10032, USA.
| | | | - Henry E Wang
- Department of Emergency Medicine, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Alexander X Lo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Health Services & Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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11
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Liu SW, Lee S, Hayes JM, Khoujah D, Lo AX, Doering M, de Wit K, Nickels CH, Kennedy M, Eagles D, Carpenter C, Arendts G, Ragsdale L. Head Computed Tomography Findings in Geriatric Emergency Department Patients with Delirium, Altered Mental Status, and Confusion: A Systematic Review. Acad Emerg Med 2022. [DOI: 10.1111/acem.14622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 10/11/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Shan W. Liu
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School Boston MA USA
| | - Sangil Lee
- Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City IA USA
| | - Jane M. Hayes
- Washington University School of Medicine St Louis MO USA
| | - Danya Khoujah
- Department of Emergency Medicine University of Maryland School of Medicine Baltimore MD USA
| | - Alexander X. Lo
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL USA
| | | | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University Kingston ON Canada
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12
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Lo AX, Rundle AG. Everyone eventually goes to ground: Distinguishing true syncope from mimics for emergency department studies on syncope in older persons. J Am Coll Emerg Physicians Open 2022; 3:e12841. [PMID: 36311341 PMCID: PMC9597094 DOI: 10.1002/emp2.12841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA,Center for Health Services & Outcomes ResearchNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Andrew G. Rundle
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
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13
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Affiliation(s)
- Alexander X. Lo
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Maura Kennedy
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
- Department of Emergency Medicine Harvard Medical School Boston Massachusetts USA
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14
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Lo AX, Wedel LK, Liu SW, Wongtangman T, Thatphet P, Santangelo I, Chary AN, Biddinger PD, Grudzen CR, Kennedy M. COVID-19 hospital and emergency department visitor policies in the United States: Impact on persons with cognitive or physical impairment or receiving end-of-life care. J Am Coll Emerg Physicians Open 2022; 3:e12622. [PMID: 35079730 PMCID: PMC8776041 DOI: 10.1002/emp2.12622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/15/2021] [Accepted: 11/23/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To characterize the national distribution of COVID-19 hospital and emergency department visitor restriction policies across the United States, focusing on patients with cognitive or physical impairment or receiving end-of-life care. METHODS Cross-sectional study of visitor policies and exceptions, using a nationally representative random sample of EDs and hospitals during the first wave of the COVID-19 pandemic, by trained study investigators using standardized instrument. RESULTS Of the 352 hospitals studied, 326 (93%) had a COVID-19 hospital-wide visitor restriction policy and 164 (47%) also had an ED-specific policy. Hospital-wide policies were more prevalent at academic than non-academic (96% vs 90%; P < 0.05) and at urban than rural sites (95% vs 84%; P < 0.001); however, the prevalence of ED-specific policies did not significantly differ across these site characteristics. Geographic region was not associated with the prevalence of any visitor policies. Among all study sites, only 58% of hospitals reported exceptions for patients receiving end-of-life care, 39% for persons with cognitive impairment, and 33% for persons with physical impairment, and only 12% provided policies in non-English languages. Sites with ED-specific policies reported even fewer exceptions for patients with cognitive impairment (29%), with physical impairments (24%), or receiving end-of-life care (26%). CONCLUSION Although the benefits of visitor policies towards curbing COVID-19 transmission had not been firmly established, such policies were widespread among US hospitals. Exceptions that permitted family or other caregivers for patients with cognitive or physical impairments or receiving end-of-life care were predominantly lacking, as were policies in non-English languages.
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Affiliation(s)
- Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
- Center for Health Services & Outcomes ResearchNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Logan K. Wedel
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Shan W. Liu
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Thiti Wongtangman
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineLerdsin General HospitalBangkokThailand
| | - Phraewa Thatphet
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineFaculty of MedicineKhon Kaen UniversityKhon KaenThailand
| | - Ilianna Santangelo
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Anita N. Chary
- Departments of Medicine and Emergency MedicineBaylor College of Medicine
| | - Paul D. Biddinger
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
- Mass General BrighamBostonMassachusettsUSA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Department of Population HealthNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
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15
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Kenny JF, Hemmert KC, Lo AX. Implementing geriatric emergency departments across a large hospital system: operational considerations and the evidence gap. J Am Coll Emerg Physicians Open 2021; 1:1288-1290. [PMID: 33392534 PMCID: PMC7771763 DOI: 10.1002/emp2.12304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- James F Kenny
- Department of Emergency Medicine Columbia University Vagelos College of Physicians and Surgeon, New York-Presbyterian Hospital New York New York USA
| | - Keith C Hemmert
- Department of Emergency Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
| | - Alexander X Lo
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA.,Center for Health Services and Outcomes Research Northwestern University Feinberg School of Medicine Chicago Illinois USA
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16
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Lo AX, Heinemann AW, Gray E, Lindquist LA, Kocherginsky M, Post LA, Dresden SM. Inter-rater Reliability of Clinical Frailty Scores for Older Patients in the Emergency Department. Acad Emerg Med 2021; 28:110-113. [PMID: 32141671 DOI: 10.1111/acem.13953] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/31/2020] [Accepted: 03/01/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Alexander X. Lo
- From the Department of Emergency MedicineNorthwestern University ChicagoIL
- the Center for Health Services and Outcomes ResearchNorthwestern University ChicagoIL
| | - Allen W. Heinemann
- From the Department of Emergency MedicineNorthwestern University ChicagoIL
- the Center for Health Services and Outcomes ResearchNorthwestern University ChicagoIL
- the Department of Physical Medicine and RehabilitationNorthwestern University ChicagoIL
| | - Elizabeth Gray
- the Department of Preventive Medicine Division of BiostatisticsNorthwestern University ChicagoIL
| | - Lee A. Lindquist
- and the Division of General Internal Medicine and Geriatrics Department of Internal MedicineNorthwestern University ChicagoIL
| | - Masha Kocherginsky
- the Department of Preventive Medicine Division of BiostatisticsNorthwestern University ChicagoIL
| | - Lori A. Post
- From the Department of Emergency MedicineNorthwestern University ChicagoIL
- Department of Medical Social SciencesNorthwestern University ChicagoIL
- Buehler Center for Health Policy and Economics Northwestern University Chicago IL
| | - Scott M. Dresden
- From the Department of Emergency MedicineNorthwestern University ChicagoIL
- the Center for Health Services and Outcomes ResearchNorthwestern University ChicagoIL
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17
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Serina P, Lo AX, Kocherginsky M, Gray E, Lindquist LA, Post LA, Heinemann AW, Cruz D, Dresden SM. The Clinical Frailty Scale and Health Services Use for Older Adults in the Emergency Department. J Am Geriatr Soc 2020; 69:837-839. [PMID: 33205408 DOI: 10.1111/jgs.16937] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/20/2020] [Accepted: 10/24/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Peter Serina
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander X Lo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Masha Kocherginsky
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elizabeth Gray
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lee A Lindquist
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lori A Post
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Allen W Heinemann
- Center for Rehabilitation Outcomes Research, Shirley Ryan AbilityLab, Chicago, Illinois, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
| | - Daniel Cruz
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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18
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Lesser A, Israni J, Lo AX, Ko KJ. Older adult visits to the emergency department for ambulatory care sensitive conditions. J Am Coll Emerg Physicians Open 2020; 1:824-828. [PMID: 33145526 PMCID: PMC7593478 DOI: 10.1002/emp2.12164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/26/2020] [Accepted: 06/01/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Ambulatory-care-sensitive conditions (ACSCs) represent emergency department (ED) visits and hospital admissions that might have been avoided through earlier primary care intervention. We characterize the current frequency and cost of ACSCs among older adults (≥65 years of age) in the ED. METHODS This study is a retrospective analysis of Centers for Medicare and Medicaid Services (CMS) national claims data distributed by the Research Data Assistance Center, a CMS contractor based at the University of Minnesota. We analyzed outpatient ED-based national claims data for visits made by traditional fee-for-service (FFS) Medicare beneficiaries in 2016. ACSCs were identified according to the Agency for Healthcare Research and Quality's Prevention Quality Indicators criteria, which require that the ACSC be the primary diagnosis for the visit. Analysis was done in Alteryx and R. RESULTS We documented nearly 1.8 million ACSC ED visits in 2016, finding that ≈10.6% of all ED visits by older adult FFS Medicare beneficiaries were associated with an ACSC. ACSC ED visits resulted in admission more often (39.7%) than non-ACSC ED visits (23.9%). Notably, 83% of patients with short-term complications from diabetes were admitted. CONCLUSIONS ED visits for a primary diagnosis of an ACSC highlight opportunities to improve access to preventive care, particularly earlier recognition and treatment of patients' deteriorating conditions that could have potentially precluded the need for the ED visit. An opportunity exists to leverage ED-based initiatives during an ACSC ED visit to support appropriate community and care transitions of these high-risk patients.
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Affiliation(s)
| | | | - Alexander X. Lo
- Department of Emergency Medicine and Center for Healthcare StudiesNorthwestern UniversityChicagoIllinoisUSA
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19
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Lo AX, Carpenter CR. Balancing Evidence and Economics While Adapting Emergency Medicine to the 21st Century's Geriatric Demographic Imperative. Acad Emerg Med 2020; 27:1070-1073. [PMID: 32335974 DOI: 10.1111/acem.13997] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Alexander X. Lo
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL USA
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago IL USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine and Emergency Care Research Core Washington University in St. Louis St. Louis MO USA
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20
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Kennedy M, Koehl J, Shenvi CL, Greenberg A, Zurek O, LaMantia M, Lo AX. The agitated older adult in the emergency department: a narrative review of common causes and management strategies. J Am Coll Emerg Physicians Open 2020; 1:812-823. [PMID: 33145525 PMCID: PMC7593470 DOI: 10.1002/emp2.12110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/12/2022] Open
Abstract
Agitation and aggression are common in older emergency department (ED) patients, can impede the expedient diagnosis of potentially life-threatening conditions, and can adversely impact ED functioning and efficiency. Agitation and aggression in older adults may be due to multiple causes, but chief among them are primary psychiatric disorders, substance use, hyperactive delirium, and symptoms of dementia. Understanding the etiology of agitation in an older adult is critical to proper management. Effective non-pharmacologic modalities are available for the management of mild to moderate agitation and aggression in patients with dementia. Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time-sensitive diagnostic imaging, procedures, and treatment. Emergency physicians have several pharmacologic agents at their disposal, including opioid and non-opioid analgesics, antipsychotics, benzodiazepines, ketamine, and combination agents. Emergency physicians should be familiar with geriatric-specific dosing, contraindications, and common adverse effects of these agents. This review article discusses the common causes and non-pharmacologic and pharmacologic management of agitation in older adults, with a specific focus on dementia, delirium, and pain.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Jennifer Koehl
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of PharmacyMassachusetts General HospitalBostonMassachusettsUSA
| | - Christina L. Shenvi
- Department of Emergency MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Allyson Greenberg
- Department of PharmacyNorthwestern Memorial HospitalChicagoIllinoisUSA
- Department of Emergency MedicineNorthwestern Memorial HospitalChicagoIllinoisUSA
| | - Olivia Zurek
- Department of PsychiatryMassachusetts General HospitalBostonMassachusettsUSA
- Department of PsychiatryHarvard Medical SchoolBostonMassachusettsUSA
| | - Michael LaMantia
- Division of Geriatric MedicineUniversity of VermontBurlingtonVermontUSA
| | - Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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21
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Lo AX. Challenging the "Scoop and Run" Model for Management of Out-of-Hospital Cardiac Arrest. JAMA 2020; 324:1043-1044. [PMID: 32930742 DOI: 10.1001/jama.2020.9245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alexander X Lo
- Feinberg School of Medicine, Department of Emergency Medicine, Northwestern University, Chicago, Illinois
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22
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Dresden SM, Lo AX, Lindquist LA, Kocherginsky M, Post LA, French DD, Gray E, Heinemann AW. The impact of Geriatric Emergency Department Innovations (GEDI) on health services use, health related quality of life, and costs: Protocol for a randomized controlled trial. Contemp Clin Trials 2020; 97:106125. [PMID: 32858227 DOI: 10.1016/j.cct.2020.106125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/12/2020] [Accepted: 08/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Older adults (age 65 and older) use the emergency department (ED) at a rate of nearly 50 ED visits per 100 older adults, accounting for over 23 million ED visits in the US annually, up to 20% of all ED visits. These ED visits are sentinel health events as discharged patients often return to the ED, experience declines in health-related quality of life (HRQoL) and disability, or are later hospitalized. Those who are admitted incur increased costs and greater risk for poor outcomes including infections, delirium, and falls. The objective of this randomized controlled trial (RCT) is to evaluate the efficacy of the Geriatric Emergency Department Innovations (GEDI) program, an ED nurse-led geriatric assessment and care coordination program, in decreasing unnecessary health services use and improving Health-Related Quality-of-Life (HRQoL) for older adults in the ED. METHODS Community dwelling older adults aged 65 and older who are vulnerable or frail according to the Clinical Frailty Scale (CFS) during an ED visit will be randomized to either GEDI (n = 420) or to usual ED care (n = 420). Outcome variables will be assessed during the ED visit and at 7-11 days and 28-32 days post ED visit. PROJECTED OUTCOMES The primary outcome is hospitalization or death within 30 days of the ED visit. Secondary outcomes include health service use outcomes (ED visits and hospitalizations), healthcare costs, and HRQoL outcomes [Patient-Reported Outcomes Measurement Information System (PROMIS) scores: PROMIS-Preference, Physical Function, Ability to Participate in Social Roles and Activities, Anxiety, and Depression]. TRIAL REGISTRATION Clinicaltrials.Gov identifier NCT04115371.
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Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Buheler Center for Health Policy and Economics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Alexander X Lo
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lee A Lindquist
- Department of Internal Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Masha Kocherginsky
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lori Ann Post
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Buheler Center for Health Policy and Economics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dustin D French
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, USA; Department of Veterans Affairs Health Services Research and Development Service, Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Elizabeth Gray
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Allen W Heinemann
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University and Center for Rehabilitation Outcomes Research, Shirley Ryan AbilityLab, USA
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23
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Southerland LT, Lo AX, Biese K, Arendts G, Banerjee J, Hwang U, Dresden S, Argento V, Kennedy M, Shenvi CL, Carpenter CR. Concepts in Practice: Geriatric Emergency Departments. Ann Emerg Med 2019; 75:162-170. [PMID: 31732374 DOI: 10.1016/j.annemergmed.2019.08.430] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 01/02/2023]
Abstract
In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Alexander X Lo
- Department of Emergency Medicine, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Glenn Arendts
- Emergency Medicine, School of Medicine, University of Western Australia, Perth, Australia
| | - Jay Banerjee
- College of Life Sciences, University of Leicester and Department of Emergency Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ula Hwang
- Department of Emergency Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
| | - Scott Dresden
- Department of Emergency Medicine, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Vivian Argento
- Geriatric Services, Bridgeport Hospital, Yale University School of Medicine, New Haven, CT
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Christina L Shenvi
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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24
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Lo AX, Donnelly JP, Durant RW, Collins SP, Levitan EB, Storrow AB, Bittner V. A National Study of U.S. Emergency Departments: Racial Disparities in Hospitalizations for Heart Failure. Am J Prev Med 2018; 55:S31-S39. [PMID: 30670199 DOI: 10.1016/j.amepre.2018.05.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/11/2018] [Accepted: 05/16/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Racial disparities in heart failure hospitalizations are well documented. The majority of heart failure hospitalizations originate from emergency departments, but emergency department hospitalization patterns for heart failure and the factors that influence hospitalization are poorly understood. This gap in knowledge was examined using a nationally representative sample of emergency department visits for heart failure. METHODS National Hospital Ambulatory Medicare Care Survey data on 2001-2010 emergency department visits were analyzed in 2015-2017 to examine age-related racial differences in hospitalization patterns for heart failure, using multivariable modified Poisson regression models. RESULTS More than 12million adult visits for heart failure to U.S. emergency departments occurred from 2001 to 2010, with 23% of visits by blacks. Overall, 71% of visits resulted in hospitalization (57% to floor beds and 14% to intensive care units). Among floor admissions for higher clinical acuity visits, whites were more likely than blacks to be hospitalized. Whites with higher clinical acuity were more likely to be hospitalized than those with lower clinical acuity (71% vs 63%, p=0.005). This expected pattern was not observed in blacks, particularly those aged ≥65years, who were hospitalized in 71% of lower clinical acuity visits, but only 61% of higher acuity visits. Among adults aged ≥65years, there was a significant interaction between clinical acuity Xrace with regard to hospitalization (p=0.037). CONCLUSIONS These results suggest age and racial disparities in hospitalization rates for emergency department patients with heart failure. The reasons for these disparities in hospitalization are unclear. Further studies on emergency department hospitalization decisions, and the impact of emergency department clinical factors, may help clarify this finding. SUPPLEMENT INFORMATION This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.
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Affiliation(s)
- Alexander X Lo
- Department of Emergency Medicine and Center for Healthcare Studies, Northwestern University, Chicago, Illinois.
| | - John P Donnelly
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Raegan W Durant
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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25
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Lo AX, Biese K. Disseminating and Sustaining Emergency Department Innovations for Older Adults: Good Ideas Deserve Better Policies. Acad Emerg Med 2018; 25:83-84. [PMID: 29077231 DOI: 10.1111/acem.13339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Alexander X. Lo
- Department of Emergency Medicine Northwestern University Northwestern University Center for Healthcare Studies Chicago IL
| | - Kevin Biese
- Department of Emergency Medicine Division of Geriatric Medicine Department of Medicine University of North Carolina at Chapel Hill Chapel Hill NC
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26
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Kennedy RE, Williams CP, Sawyer P, Lo AX, Connelly K, Nassel A, Brown CJ. Life-Space Predicts Health Care Utilization in Community-Dwelling Older Adults. J Aging Health 2017; 31:280-292. [PMID: 29254407 DOI: 10.1177/0898264317730487] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine whether decline in life-space mobility predicts increased health care utilization among community-dwelling older adults. METHOD Health care utilization (number of emergency department [ED] visits and hospitalizations) was self-reported during monthly interviews among 419 community-dwelling African American and non-Hispanic White adults aged 75 years and older in The University of Alabama at Birmingham (UAB) Study of Aging II. Life-space was measured using the UAB Life-Space Assessment. Generalized estimating equations were used to examine associations of life-space at the beginning of each interval with health care utilization over the 1-month interval. RESULTS Overall, 400 participants were followed for 36 months. A 10-point decrease in life-space was associated with 14% increased odds of an ED visit and/or hospitalization over the next month, adjusting for demographics, transportation difficulty, comorbidity, and having a doctor visit in the last month. DISCUSSION Life-space is a practical alternative in predicting future health care utilization to performance-based measures, which can be difficult to incorporate into clinical or public health practice.
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Lo AX, Flood KL, Biese K, Platts-Mills TF, Donnelly JP, Carpenter CR. Factors Associated With Hospital Admission for Older Adults Receiving Care in U.S. Emergency Departments. J Gerontol A Biol Sci Med Sci 2017; 72:1105-1109. [PMID: 28329790 DOI: 10.1093/gerona/glw207] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 09/28/2016] [Indexed: 11/13/2022] Open
Abstract
Background Emergency departments (EDs) play a growing role in hospital admissions for older adults, yet nationally representative data on predictors of admission from the EDs are limited. Methods We examined sociodemographic, clinical, and hospital characteristics associated with non-ICU admissions, using National Hospital Ambulatory Medical Care Survey data and multivariate Poisson regression models. Results There were an estimated 175 million ED visits by adults older than 65 years from 2001 to 2010. Overall, 32.5% were admitted to non-ICU beds. In multivariate analysis, non-ICU admission was associated with increasing age (16% higher per 10-year increase in age), white versus black race (35% vs 31%), and EDs in the Northeast (40%) or Midwest (38%) versus South (31%) or West (30%). Conclusion Non-ICU admission rates for older adults receiving care in U.S. EDs vary by age, race, and region. Understanding the reasons for these disparities in hospitalization rates may guide interventions to reduce hospitalizations in older adults.
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Affiliation(s)
| | - Kellie L Flood
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
| | | | - John P Donnelly
- Department of Epidemiology, University of Alabama at Birmingham
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28
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Lo AX, Rundle AG, Buys D, Kennedy RE, Sawyer P, Allman RM, Brown CJ. Neighborhood Disadvantage and Life-Space Mobility Are Associated with Incident Falls in Community-Dwelling Older Adults. J Am Geriatr Soc 2017; 64:2218-2225. [PMID: 27869994 DOI: 10.1111/jgs.14353] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To determine the relationship between neighborhood-level socioeconomic characteristics, life-space mobility, and incident falls in community-dwelling older adults. DESIGN Prospective, observational cohort study with a baseline in-home assessment and 6-month telephone follow-up. SETTING Central Alabama. PARTICIPANTS Community-dwelling adults aged 65 and older recruited from a random sample of Medicare beneficiaries (N = 1,000). MEASUREMENTS Neighborhood disadvantage was measured using a composite index derived from baseline neighborhood-level residential census tract socioeconomic variables. Data on individual-level socioeconomic characteristics, clinical variables, and life-space collected at baseline were included as covariates in a multivariate model using generalized estimating equations to assess the association with incident falls in the 6 months after baseline. RESULTS Of the 940 participants who completed baseline and follow-up assessments, 126 (13%) reported one or more new falls in the 6 months after baseline. There was an independent nonlinear association between neighborhood disadvantage (according to increasing quartiles of disadvantage) and incident falls after adjusting for confounders: The lowest quartile served as reference; 2nd quartile odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.2-4.6; 3rd quartile OR = 1.9, 95% CI = 1.0-3.7; 4th quartile OR = 3.2, 95% CI = 1.7-6.0. Each 10-point decrement in life-space (OR = 1.2, 95% CI = 1.0-1.3) was associated with a higher risk of falls. CONCLUSION Greater neighborhood disadvantage was associated with greater risk of falls. Life-space also contributes separately to fall risk. Community-dwelling older adults in disadvantaged neighborhoods, particularly those with limited mobility, may benefit from a more-rigorous assessment of their fall risk by healthcare providers. Neighborhood level socioeconomic characteristics should also be an important consideration when identifying vulnerable populations that may benefit the most from fall prevention programs.
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Affiliation(s)
- Alexander X Lo
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Comprehensive Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew G Rundle
- Department of Epidemiology, Columbia University, New York, New York
| | - David Buys
- Department of Food Science, Nutrition, and Health Promotion, Mississippi State University, Mississippi State, Mississippi.,Mississippi Agricultural and Forestry Experiment Station, Mississippi State, Mississippi
| | - Richard E Kennedy
- Comprehensive Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patricia Sawyer
- Comprehensive Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard M Allman
- Geriatrics and Extended Care Services, Office of Patient Care Services, Veterans Health Administration, Washington, District of Columbia
| | - Cynthia J Brown
- Comprehensive Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Geriatric Research, Education, and Clinical Center, Birmingham/Atlanta Veterans Affairs, Birmingham, Alabama
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Kennedy RE, Sawyer P, Williams CP, Lo AX, Ritchie CS, Roth DL, Allman RM, Brown CJ. Life-Space Mobility Change Predicts 6-Month Mortality. J Am Geriatr Soc 2017; 65:833-838. [PMID: 28152168 DOI: 10.1111/jgs.14738] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine 6-month change in life-space mobility as a predictor of subsequent 6-month mortality in community-dwelling older adults. DESIGN Prospective cohort study. SETTING Community-dwelling older adults from five Alabama counties in the University of Alabama at Birmingham (UAB) Study of Aging. PARTICIPANTS A random sample of 1,000 Medicare beneficiaries, stratified according to sex, race, and rural or urban residence, recruited between November 1999 and February 2001, followed by a telephone interview every 6 months for the subsequent 8.5 years. MEASUREMENTS Mortality data were determined from informant contacts and confirmed using the National Death Index and Social Security Death Index. Life-space was measured at each interview using the UAB Life-Space Assessment, a validated instrument for assessing community mobility. Eleven thousand eight hundred seventeen 6-month life-space change scores were calculated over 8.5 years of follow-up. Generalized linear mixed models were used to test predictors of mortality at subsequent 6-month intervals. RESULTS Three hundred fifty-four deaths occurred within 6 months of two sequential life-space assessments. Controlling for age, sex, race, rural or urban residence, and comorbidity, life-space score and life-space decline over the preceding 6-month interval predicted mortality. A 10-point decrease in life-space resulted in a 72% increase in odds of dying over the subsequent 6 months (odds ratio = 1.723, P < .001). CONCLUSIONS Life-space score at the beginning of a 6-month interval and change in life-space over 6 months were each associated with significant differences in subsequent 6-month mortality. Life-space assessment may assist clinicians in identifying older adults at risk of short-term mortality.
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Affiliation(s)
- Richard E Kennedy
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Comprehensive Center for Healthy Aging, Birmingham, Alabama
| | - Patricia Sawyer
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Comprehensive Center for Healthy Aging, Birmingham, Alabama
| | - Courtney P Williams
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alexander X Lo
- Comprehensive Center for Healthy Aging, Birmingham, Alabama.,Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California at San Francisco, San Francisco, California.,Jewish Home San Francisco, San Francisco, California
| | - David L Roth
- Division of Geriatric Medicine and Gerontology, Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland
| | - Richard M Allman
- Geriatrics and Extended Care Services, Office of Patient Care Services, Veterans Health Administration, Washington, District of Columbia
| | - Cynthia J Brown
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Comprehensive Center for Healthy Aging, Birmingham, Alabama.,Geriatric Research, Education, and Clinical Center, Birmingham/Atlanta Veterans Affairs, Birmingham, Alabama
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Brown CJ, Kennedy RE, Lo AX, Williams CP, Sawyer P. Impact of Emergency Department Visits and Hospitalization on Mobility Among Community-Dwelling Older Adults. Am J Med 2016; 129:1124.e9-1124.e15. [PMID: 27288857 PMCID: PMC5039061 DOI: 10.1016/j.amjmed.2016.05.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/22/2016] [Accepted: 05/23/2016] [Indexed: 01/16/2023]
Abstract
PURPOSE The study purpose was to assess the effects of emergency department visits on mobility as measured by Life-Space Assessment (LSA) scores and to compare life-space trajectories associated with emergency department visit only, hospitalization, and no event. METHODS A total of 410 community-dwelling adults aged ≥75 years who were living in the community, were able to communicate by telephone, could schedule an in-home interview, and could answer questions independently were followed from June 2010 to August 2014. In-home baseline and monthly telephone follow-up interviews collected data on LSA scores, emergency department use, and hospitalizations. Life-space is measured using a validated patient-reported tool reflecting community mobility and quality of life. Trajectories of LSA before and after an emergency department visit or hospitalization were compared with no event occurrence. RESULTS Mean age of participants was 81.7 years (standard deviation, 4.8); 57% were female, and 35% were African American. During 3 years of follow-up, 83 persons (20%) had an emergency department visit without subsequent hospitalization and 164 persons (40%) were hospitalized. Although baseline LSA scores were similar, in the month after an emergency department visit, adjusted LSA scores decreased by 6.1 points (P = .01) in comparison with hospitalized participants who experienced an average decrease of 18.0 points (P < .0001). Neither those with an emergency department visit only nor those with hospitalization recovered to their prior level of community mobility. Moreover, those with an emergency department visit showed no significant improvement in LSA scores up to 1 year later. CONCLUSIONS Older adults who experienced an emergency department visit or hospitalization had an associated decrease in community mobility without significant recovery.
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Affiliation(s)
- Cynthia J Brown
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Ala; Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham.
| | - Richard E Kennedy
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
| | - Alexander X Lo
- Department of Emergency Medicine, University of Alabama at Birmingham
| | - Courtney P Williams
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
| | - Patricia Sawyer
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
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Lo AX, Flood KL, Kennedy RE, Bittner V, Sawyer P, Allman RM, Brown CJ. The Association Between Life-Space and Health Care Utilization in Older Adults with Heart Failure. J Gerontol A Biol Sci Med Sci 2015. [PMID: 26219849 DOI: 10.1093/gerona/glv076] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Life-space is associated with adverse health outcomes in older adults, but its role in health care utilization among individuals with heart failure is not well understood. We examined the relationship between life-space and both emergency department (ED) utilization and hospitalization. METHODS Participants were community-dwelling older adults with a verified diagnosis of heart failure who completed a baseline in-home assessment and at least one follow-up telephone interview. Life-space was measured at baseline and at follow-up every 6 months for 8.5 years. Poisson models were used to determine the association between life-space, measured at the beginning of each 6-month interval, and health care utilization, defined as ED utilization or hospitalization in the immediate ensuing 6 months, adjusting for sociodemographic and clinical confounders. RESULTS A total of 147 participants contributed 259 total health care utilization events involving an ED visit or a hospital admission. Multivariate analysis demonstrated an inverse association between life-space and health care utilization, where a clinically significant 10-point difference in life-space was independently associated with a 14% higher rate of ED utilization or hospitalization (incidence rate ratio 1.14, 95% CI 1.04-1.26, p = .004). CONCLUSIONS Life-space may be a useful identifier of community-dwelling older adults with heart failure at increased risk of ED visits or hospital admissions in the ensuing 6 months. Life-space may therefore be a potentially important component of intervention programs to reduce health care utilization.
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Affiliation(s)
- Alexander X Lo
- Department of Emergency Medicine, Comprehensive Center for Healthy Aging, and
| | - Kellie L Flood
- Comprehensive Center for Healthy Aging, and Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | - Richard E Kennedy
- Comprehensive Center for Healthy Aging, and VA Geriatric Research, Education, and Clinical Center, Birmingham, Alabama
| | - Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - Patricia Sawyer
- Comprehensive Center for Healthy Aging, and Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | - Richard M Allman
- Geriatrics and Extended Care Services, Office of Patient Care Services, Veterans Health Administration, Washington, DC
| | - Cynthia J Brown
- Comprehensive Center for Healthy Aging, and Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham. VA Geriatric Research, Education, and Clinical Center, Birmingham, Alabama
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Carpenter CR, Lo AX. Falling behind? Understanding implementation science in future emergency department management strategies for geriatric fall prevention. Acad Emerg Med 2015; 22:478-80. [PMID: 25773739 DOI: 10.1111/acem.12628] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Christopher R. Carpenter
- Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Alexander X. Lo
- Department of Emergency Medicine; University of Alabama-Birmingham School of Medicine; Birmingham AL
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Lo AX, Donnelly JP, McGwin G, Bittner V, Ahmed A, Brown CJ. Impact of gait speed and instrumental activities of daily living on all-cause mortality in adults ≥65 years with heart failure. Am J Cardiol 2015; 115:797-801. [PMID: 25655868 DOI: 10.1016/j.amjcard.2014.12.044] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 12/19/2014] [Accepted: 12/19/2014] [Indexed: 12/12/2022]
Abstract
Mobility and function are important predictors of survival. However, their combined impact on mortality in adults ≥65 years with heart failure (HF) is not well understood. This study examined the role of gait speed and instrumental activities of daily living (IADL) in all-cause mortality in a cohort of 1,119 community-dwelling Cardiovascular Health Study participants ≥65 years with incident HF. Data on HF and mortality were collected through annual examinations or contact during the 10-year follow-up period. Slower gait speed (<0.8 m/s vs ≥0.8 m/s) and IADL impairment (≥1 vs 0 areas of dependence) were determined from baseline and follow-up assessments. A total of 740 (66%) of the 1,119 participants died during the follow-up period. Multivariate Cox proportional hazards models showed that impairments in either gait speed (hazard ratio 1.37, 95% confidence interval 1.10 to 1.70; p = 0.004) or IADL (hazard ratio 1.56, 95% confidence interval 1.29-1.89; p <0.001), measured within 1 year before the diagnosis of incident HF, were independently associated with mortality, adjusting for sociodemographic and clinical characteristics. The combined presence of slower gait speed and IADL impairment was associated with a greater risk of mortality and suggested an additive relation between gait speed and IADL. In conclusion, gait speed and IADL are important risk factors for mortality in adults ≥65 years with HF, but the combined impairments of both gait speed and IADL can have an especially important impact on mortality.
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Affiliation(s)
- Alexander X Lo
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Comprehensive Center for Healthy Aging, Birmingham, Alabama.
| | - John P Donnelly
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama; Department of Medicine, Center for Outcomes and Effectiveness Research Education, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gerald McGwin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Vera Bittner
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ali Ahmed
- Veterans Affairs Medical Center, Washington, District of Columbia
| | - Cynthia J Brown
- Comprehensive Center for Healthy Aging, Birmingham, Alabama; Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Birmingham, Alabama
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Carpenter CR, Avidan MS, Wildes T, Stark S, Fowler SA, Lo AX. Predicting geriatric falls following an episode of emergency department care: a systematic review. Acad Emerg Med 2014; 21:1069-82. [PMID: 25293956 DOI: 10.1111/acem.12488] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/19/2014] [Accepted: 06/21/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored. OBJECTIVES This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factor's accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity. METHODS A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED. RESULTS A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%. CONCLUSIONS This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk.
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Affiliation(s)
| | | | - Tanya Wildes
- The Department of Medicine Division of Medical Oncology; St. Louis MO
| | - Susan Stark
- The Department of Occupational Therapy; St. Louis MO
- The Department of Neurology; St. Louis MO
| | - Susan A. Fowler
- Washington University in St. Louis School of Medicine; St. Louis MO
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Abstract
OBJECTIVES To determine the effect of falls and fractures on life-space mobility in a cohort of community-dwelling older adults. DESIGN Prospective, observational study with a baseline in-home assessment and 6-month telephone follow-up interviews over 4 years. SETTING Central Alabama. PARTICIPANTS Community-dwelling adults aged 65 and older recruited from a random sample of Medicare beneficiaries stratified according to sex, race, and urban versus rural residence (N = 970). MEASUREMENTS Sociodemographic factors, medical history, depressive symptoms (Geriatric Depression Scale), cognitive function (Mini-Mental State Examination), mobility-related symptoms, transportation difficulty, and healthcare use were assessed during a baseline in-home interview of participants. Life-space mobility and falls or injuries (including fractures) were assessed at the baseline interview and at 6-month intervals in follow-up telephone calls. RESULTS Four hundred fifty-four (47%) participants reported at least one fall during the 4-year follow-up. The life-space score fell 3.2 points from the beginning to the end of the 6-month interval during which a fall occurred, adjusting for other known predictors of decline in life-space mobility. The decrease in interval life-space score was progressively greater for a fall and an injury (-4.7 points), a fall and a fracture (-14.2 points), and a fall and a hip fracture (-23.6 points). CONCLUSION Falls, whether associated with an injury or not, were independently associated with a decrease in life-space mobility in the ensuing 6 months. Further studies are needed to determine reasons for life-space mobility decline in community-dwelling older adults with incident falls without any injuries.
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Affiliation(s)
- Alexander X Lo
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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