OBJECTIVES
To characterize assessments of a patient's ability to report elder abuse within the context of an emergency department (ED)–based screen for elder abuse.
DESIGN
Cross‐sectional study in ...which participants were screened for elder abuse and neglect.
SETTING
Academic ED in the United States.
PARTICIPANTS
Patients, aged 65 years and older, presenting to an ED for acute care were assessed by trained research assistants or nurses.
MEASUREMENTS
All patients completed the four‐item Abbreviated Mental Test 4 (AMT4), then completed a safety interview (using the Emergency Department Senior Abuse Identification tool) designed to detect multiple domains of elder abuse and received a physical examination. Based on the cognitive assessment and safety interview, assessors ranked their confidence in the patient's ability to report abuse as absolutely confident, confident, somewhat confident, or not confident. To assess interrater reliability, two assessors independently rated confidence for a subset of patients.
RESULTS
Assessors suspected elder abuse in 18 of 276 patients (6.5%). Assessors were absolutely confident in the patient's ability to report abuse for 95.7% of patients, confident for 2.5%, somewhat confident for 1.5%, and not confident for 0.3%. Among patients with an AMT4 of 4 (n = 249), assessors were confident or absolutely confident in 100% of patients. Among patients with an AMT4 of less than 4 (n = 27), they were confident or absolutely confident in the patient's ability to report abuse for 81% of patients, including 11 of 12 patients with mild cognitive impairment and 7 of 11 patients with severe cognitive impairment. For patients receiving paired evaluations (n = 131), agreement between assessors regarding patient ability to report abuse was 97% (κ = 0.5).
CONCLUSIONS
In this sample of older adults receiving care in an ED, research assistants and nurses felt that the vast majority were able to report elder abuse, including many patients with cognitive impairment. J Am Geriatr Soc 68:170–175, 2019
Background The Affordable Care Act led to improvements in reporting a usual source of care, but it is unclear whether patients are changing their usual source of care in response to coverage gains. ...We assess whether prior insurance instability is associated with changes in use of emergency and office-based care after the Marketplace and Medicaid expansion were introduced. Methods Our study draws from the 2013-14 Medical Expenditure Panel Survey, identifying a cohort of non-elderly adults with full-year health insurance coverage in 2014. We use linear and multinomial logistic regression to assess the relationship between insurance instability prior to 2014 (uninsured for 1-11 months, greater than or equal to12 months) and person-level changes in use of health care after gaining coverage (change in ED and office visits from 2013 to 2014) with continuously insured individuals serving as a comparison group. Results Being uninsured for at least one year prior to gaining full-year coverage in 2014 was associated with a 33% increase in ED visits (0.06 visits, p0.01) and a 47% increase in office visits (1.10 visits, p0.01), driven by those gaining public coverage. We found no evidence of substitution across settings in the short term, often a stated goal of expansion. Conclusion The long-term uninsured may have substantial health needs and pent-up demand for health care, seeing more physicians across multiple settings in the year after gaining coverage as they seek to get unmanaged conditions under control. Closing the gap in primary care use between the previously uninsured and those with health insurance coverage may help improve long-term health outcomes.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Study objective We estimate the prevalence of malnutrition among older patients presenting to an emergency department (ED) in the southeastern United States and identify subgroups at increased risk. ...Methods We conducted a cross-sectional study with random time block sampling of cognitively intact patients aged 65 years and older. Nutrition was assessed with the Mini Nutritional Assessment Short-Form (0 to 14 scale), with malnutrition defined as a score of 7 or less and at risk for malnutrition defined as a score of 8 to 11. The presence of depressive symptoms was defined as a Center for Epidemiological Studies Depression–10 score of 4 or more (0 to 10 scale). Results Among 138 older adults, 16% (95% confidence interval CI 11% to 23%) were malnourished and 60% (95% CI 52% to 68%) were either malnourished or at risk for malnutrition. Seventeen of the 22 malnourished patients (77%) denied previously receiving a diagnosis of malnutrition. The prevalence of malnutrition was not appreciably different between men and women, across levels of patient education, or between those living in urban and rural areas. However, the prevalence of malnutrition was higher among patients with depressive symptoms (52%), those residing in assisted living (44%), those with difficulty eating (38%), and those reporting difficulty buying groceries (33%). Conclusion Among a random sample of cognitively intact older ED patients, more than half were malnourished or at risk for malnutrition, and the majority of malnourished patients had not previously received a diagnosis. Higher rates of malnutrition among individuals with depression, difficulty eating, and difficulty buying groceries suggest the need to explore multifaceted interventions.
Objectives
Health outcomes among older emergency department (ED) patients may be influenced by physical, economic, and psychological problems not routinely identified during the ED visit. The ...objective of this study was to characterize such problems among older adults presenting to the ED.
Methods
This was a prevalence study with enrollment during 4‐hour periods randomly selected between 9 a.m. and 9 p.m. on random days of the week over a period of 8 weeks at an academic ED in the southeast United States. Participants were noninstitutionalized, cognitively intact adults aged 65 years or older without life‐threatening illness or injury. Consenting patients were asked about the frequency of 10 prespecified problems during the past year.
Results
Patients (N = 138) were non‐Hispanic white (69%) and female (57%) and almost all had primary providers (95%) and health insurance (98%). Forty percent reported their overall health as fair (21%) or poor (19%). Hazardous drinking habits were reported by 10% of patients. The prevalence of problems occurring either “sometimes” or “often” in the past year were pain (60%), difficulty walking (47%), lack of money (32%), isolation and loneliness (14%), lack of transportation (12%), difficulty scheduling a doctor's appointment (4%), difficulty getting prescriptions filled (4%), and lack of dental care (6%). Nine patients (7%) reported experiencing physical or psychological abuse at some point in the past year. Females, minorities, and individuals living in urban areas reported higher rates of most problems.
Conclusions
Nonmedical problems are common among cognitively intact, independent living, non–critically ill older patients presenting to an ED in the southeast United States.
Resumen
Objetivos
Los resultados de salud en los pacientes mayores del servicio de urgencias (SU) pueden estar influidos por problemas físicos, económicos y psicológicos que no son identificados rutinariamente durante la visita al SU. El objetivo de este estudio fue caracterizar estos problemas en los adultos mayores que acuden al SU.
Metodología
Estudio de prevalencia que incluyó pacientes durante periodos de 4 horas seleccionados aleatoriamente entre las 9 a.m. y las 9 p.m. en días de la semana durante un periodo de 8 semanas en un SU universitario del sureste de Estados Unidos. Los participantes fueron adultos de 65 años o más cognitivamente intactos, no institucionalizados y sin lesiones o enfermedades potencialmente mortales. Se preguntó a los pacientes que firmaron el consentimiento informado por la frecuencia durante el año de diez problemas prespecificados anterior.
Resultados
Los pacientes (N = 138) fueron predominantemente blancos no hispanos (69%), mujeres (57%), y casi todos tenían un proveedor principal (95%) y un seguro médico (98%). Un 40% documentó su salud global como justa (21%) o mala (19%). Se documentaron hábitos alcohólicos de riesgo en un 10% de los pacientes. La prevalencia de problemas que ocurrieron tanto “a veces” como “a menudo” en el pasado año fueron: dolor (60%), dificultad para caminar (47%), falta de dinero (32%), aislamiento y soledad (14%), falta de medio de transporte (12%), dificultad para concertar una cita con el médico (4%), dificultades para obtener medicamentos con receta (4%) y falta de cuidado dental (6%). Nueve pacientes (7%) documentaron haber experimentado abusos físicos o psicológicos en algún momento del pasado año. Las mujeres, las minorías y los individuos residentes en áreas urbanas documentaron porcentajes más altos de la mayoría de los problemas.
Conclusiones
Los problemas no médicos son comunes entre los pacientes mayores no enfermos de gravedad, cognitivamente intactos e independientes para la vida diaria que acuden a los SU en el sureste de Estados Unidos.
Feeling FAINT? Watch Out for the Grizzlies Jones, Christopher W.; Platts-Mills, Timothy F.
Annals of emergency medicine,
February 2020, 2020-02-00, 20200201, Letnik:
75, Številka:
2
Journal Article
Alternative management methods are essential to ensure high-quality and efficient emergency care for the growing number of geriatric adults worldwide. Protocols to support early condition-specific ...treatment of older adults with acute severe illness and injury are needed. Improved emergency department care for older adults will require providers to address the influence of other factors on the patient's health. This article describes recent and ongoing efforts to enhance the quality of emergency care for older adults using alternative management approaches spanning the spectrum from prehospital care, through the emergency department, and into evolving inpatient or outpatient processes of care.
Study objective The purpose of this study is to determine whether older adults presenting to the emergency department (ED) with pain are less likely to receive pain medication than younger adults. ...Methods Pain-related visits to US EDs were identified with reason-for-visit codes from 7 years (2003 to 2009) of the National Hospital Ambulatory Medical Care Survey. The primary outcome was the administration of an analgesic. The percentage of patients receiving analgesics in 4 age groups was adjusted for measured covariates, including pain severity. Results Pain-related visits accounted for 88,031 (46.9%) ED visits by patients aged 18 years or older during the 7-year period. There were 7,585 pain-related ED visits by patients aged 75 years or older, representing an estimated 3.65 million US ED visits annually. In comparing survey-weighted unadjusted estimates, pain-related visits by patients aged 75 years or older were less likely than visits by patients aged 35 to 54 years to result in administration of an analgesic (49% versus 68.3%) or an opioid (34.8% versus 49.3%). Absolute differences in rates of analgesic and opioid administration persisted after adjustment for sex, race/ethnicity, pain severity, and other factors and multiple imputation of missing pain severity data, with visits by patients aged 75 years and older being 19.6% (95% confidence interval 17.8% to 21.4%) less likely than visits by patients aged 35 to 54 years to receive an analgesic and 14.6% (95% confidence interval 12.8% to 16.4%) less likely to receive an opioid. Conclusion Patients aged 75 years and older with pain-related ED visits are less likely to receive pain medication than patients aged 35 to 54 years.
ObjectiveTo test whether providing relevant clinical trial registry information to peer reviewers evaluating trial manuscripts decreases discrepancies between registered and published trial ...outcomes.DesignStepped wedge, cluster-randomised trial, with clusters comprised of eligible manuscripts submitted to each participating journal between 1 November 2018 and 31 October 2019.SettingThirteen medical journals.ParticipantsManuscripts were eligible for inclusion if they were submitted to a participating journal during the study period, presented results from the primary analysis of a clinical trial, and were peer reviewed.InterventionsDuring the control phase, there were no changes to pre-existing peer review practices. After journals crossed over into the intervention phase, peer reviewers received a data sheet describing whether trials were registered, the initial registration and enrolment dates, and the registered primary outcome(s) when enrolment began.Main outcome measureThe presence of a clearly defined, prospectively registered primary outcome consistent with the primary outcome in the published trial manuscript, as determined by two independent outcome assessors.ResultsWe included 419 manuscripts (243 control and 176 intervention). Participating journals published 43% of control-phase manuscripts and 39% of intervention-phase manuscripts (model-estimated percentage difference between intervention and control trials = −10%, 95% CI −25% to 4%). Among the 173 accepted trials, published primary outcomes were consistent with clearly defined, prospectively registered primary outcomes in 40 of 105 (38%) control-phase trials and 27 of 68 (40%) intervention-phase trials. A linear mixed model did not show evidence of a statistically significant primary outcome effect from the intervention (estimated difference between intervention and control=−6% (90% CI −27% to 15%); one-sided p value=0.68).ConclusionsThese results do not support use of the tested intervention as implemented here to increase agreement between prospectively registered and published trial outcomes. Other approaches are needed to improve the quality of outcome reporting of clinical trials.Trial registration numberISRCTN41225307.
In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and a strained ...health care system. In response, geriatric emergency medicine (EM) clinicians, educators, and researchers collaborated with the American College of Emergency Physicians (ACEP), American Geriatrics Society (AGS), Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM) to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations; equipment; policies; and protocols. These “Geriatric Emergency Department Guidelines” represent the first formal society‐led attempt to characterize the essential attribute of the geriatric ED and received formal approval from the boards of directors for each of the four societies in 2013 and 2014. This article is intended to introduce EM and geriatric health care providers to the guidelines, while providing proposals for educational dissemination, refinement via formal effectiveness evaluations and cost‐effectiveness studies, and institutional credentialing.
Resumen
En Estados Unidos y en el resto del mundo, la efectividad, la eficiencia y las estrategias fiables para proporcionar atención urgente a los adultos mayores es un reto para los servicios de urgencias (SU) saturados y un sistema sanitario sobrecargado. En respuesta, los clínicos, profesores e investigadores de la Medicina de Urgencias y Emergencias (MUE) Geriátrica, en colaboración con el American College of Emergency Physicians, la American Geriatrics Society, la Emergency Nurses Association y la Society for Academic Emergency Medicine, han desarrollado unas guías clínicas con la intención de mejorar la atención geriátrica en el SU mediante la mejora de los conocimientos, la formación y las expectativas de mejora de la calidad; el equipamiento; las políticas; y los protocolos. Estas Guías Clínicas del Servicio de Urgencias Geriátrico representan el primer intento formal liderado por la Sociedad para describir las características esenciales de un SU geriátrico, y recibieron la aprobación formal del Consejo Directivo de cada una de las cuatro sociedades en 2013 y 2014. Este artículo pretende presentar a los sanitarios de la MUE y la atención sanitaria geriátrica estas guías clínicas, a la vez que proporcionan propuestas para la divulgación formativa, el refinamiento formal de las evaluaciones de la efectividad y de coste‐efectividad y las instituciones de acreditación.
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