REVIEW ARTICLE

Emergency Department Interventions for Older Adults:

A Systematic Review
Jaime M. Hughes, PhD, MPH, MSW,*†‡ Caroline E. Freiermuth, MD, MHSc,§
Megan Shepherd-Banigan, PhD,*† Luna Ragsdale, MD,§ Stephanie A. Eucker, MD, PhD,§
Karen Goldstein, MD, MSPH,*¶ S. Nicole Hastings, MD, MHS,*†‡k
Rachel L. Rodriguez, PhD, MPH,** Jessica Fulton, PhD,** Katherine Ramos, PhD,*‡k
Amir Alishahi Tabriz, MD, PhD, MPH,†† Adelaide M. Gordon, MPH,* Jennifer M. Gierisch, PhD,*†¶
Andrzej Kosinski, PhD,‡‡ and John W. Williams Jr MD, MHSc*¶

[“bridge”]). The effect of ED interventions on clinical (func-

OBJECTIVES: To evaluate the effect of emergency depart- tional status, quality of life [QOL]), patient experience, and
ment (ED) interventions on clinical, utilization, and care utilization (hospitalization, ED return visit) outcomes was
experience outcomes for older adults. evaluated.
DESIGN: A conceptual model informed, protocol-based RESULTS: A total of 2000 citations were identified; 17 articles
systematic review. describing 15 unique studies (9 randomized and 6 nonrando-
SETTING: Emergency Department (ED). mized) met eligibility criteria and were included in analyses. ED
interventions showed a mixed pattern of effects. Overall, there
PARTICIPANTS: Older adults 65 years of age and older.
was a small positive effect of ED interventions on functional
METHODS AND MEASUREMENT: Medline, Embase, status but no effects on QOL, patient experience, hospitaliza-
CINAHL, and PsycINFO were searched for English-language tion at or after the initial ED index visit, or ED return visit.
studies published through December 2017. Studies evaluating
CONCLUSION: Studies using two or more intervention
the use of one or more eligible intervention strategies (discharge
strategies may be associated with the greatest effects on
planning, case management, medication safety or management,
clinical and utilization outcomes. More comprehensive
and geriatric EDs including those that cited the 2014 Geriatric
interventions, defined as those with all three key interven-
ED Guidelines) with adults 65 years of age and older were
tion components present, may be associated with some pos-
included. Studies were classified by the number of intervention
itive outcomes. J Am Geriatr Soc 00:1–10, 2019.
strategies used (ie, single strategy or multi-strategy) and key
intervention components present (ie, assessment, referral plus
follow-up, and contact both before and after ED discharge Key words: geriatric emergency medicine; emergency
department; interventions

From the *Center for Health Services Research in Primary Care, Durham
VA Health Care System, Durham, North Carolina; †Department of
Population Health Sciences, Duke University School of Medicine, Durham,
North Carolina; ‡Center for the Study of Aging and Human Development,
Duke University School of Medicine, Durham, North Carolina; §Division of
Emergency Medicine, Duke University School of Medicine, Durham, North
Carolina; ¶Division of General Internal Medicine, Duke University School
of Medicine, Durham, North Carolina; kGeriatric Research, Education, and
Clinical Center, Durham VA Health Care System, Durham, North
O lder adults have some of the highest rates of emer-
gency department (ED) visits. In the United States,
older adults make 64 ED visits per 100 persons annually,
Carolina; **Psychology Service, Durham VA Health Care System, Durham, nearly twice the frequency of their younger counterparts.1
North Carolina; ††Division of Pharmaceutical Outcomes and Policy, UNC
Challenges that impact ED care for this patient population
Eshelman School of Pharmacy, Chapel Hill, North Carolina; and the
‡‡
Department of Biostatistics & Bioinformatics, Duke University, Durham, include multiple morbidities, atypical symptoms or disease
North Carolina. states, polypharmacy and adverse drug-drug interactions,
Address correspondence to Jaime M. Hughes, Duke University School of and misunderstandings or misuse of prescription and over-
Medicine, 215 Morris Street, Suite 210, Durham, NC 27701; E-mail: jaime. the-counter medications.2,3 Additionally, older adults may
[email protected] be challenged by functional disabilities, impaired cognition,
DOI: 10.1111/jgs.15854 communication problems, and reduced social support.4,5

JAGS 00:1–10, 2019

© 2019 The American Geriatrics Society 0002-8614/18/$15.00
2 HUGHES ET AL. MONTH 2019–VOL. 00, NO. 00 JAGS

Together, these challenges can negatively impact the care Our review was informed by a conceptual model
received while in the ED, transitions to home or other set- (Figure S1) that drew on previously published models.20,21
tings, and postdischarge health outcomes and utilization We followed a standard protocol for all steps of this review
patterns including hospitalization and ED return visits.6,7 (PROSPERO: CRD42018087660). Our full report, refer-
A broad range of interventions have been designed to enced earlier, is available at https://www.hsrd.research.va.
improve clinical and utilization outcomes in older adults who gov/publications/esp.
visit the ED. Broadly speaking, these interventions can be
grouped into several categories including staffing, physical
Search Strategy
infrastructure, care delivery (including functional and geriatric
assessments, and risk prediction tools), case management, and Our study protocol, including search strategy and detailed
transitional care or discharge planning.8–12 Existing reviews identification of intervention strategies and components,
have classified interventions globally rather than identifying was developed a priori in collaboration with the partners,
details of the intervention structure and its components. This TEP, and project team previously described. Intervention
global approach may potentially obscure relationships between strategies and components were identified based on prior liter-
components of the intervention structure and outcomes. Fur- ature22,23 and Effective Practice and Organization of Care
ther, most prior studies of geriatric ED practices have focused (EPOC) guidelines,24 and finalized through a series of collabo-
on utilization outcomes; few prior studies have included clinical rative iterative discussions. We conducted searches of Medline
outcomes such as functional status. (via PubMed), Embase, CINAHL, and PsycINFO for English-
The past decade has seen growing attention on geriatric language studies published through December 2017 evaluat-
emergency medicine, as evident by an increasing number of ing interventions for older adults using the ED (Table S1). We
special interest groups within professional organizations, also reviewed bibliographies of relevant review articles. In an
initiatives sponsored by the Centers for Medicare & Medic- effort to identify research currently in progress, including stud-
aid such as GEDI WISE,13 and the publication of research ies that cited the 2014 Geriatric ED Guidelines, we also
priorities advocating for additional work focusing on the searched ClinicalTrials.gov and performed a targeted search
structure of ED services and the impact of ED care on func- of Scopus for relevant conference abstracts.
tion and other patient-prioritized outcomes.14,15 Perhaps
the most recognized initiative was the publication of Geriat-
Study Selection
ric Emergency Department Guidelines in 2014.16–19 These
guidelines offer a “template” of recommendations in devel- Using prespecified eligibility criteria (Table S2), titles and
oping a “geriatric-friendly ED.” Recommendations focus on abstracts identified through our initial search were reviewed
staffing, administration, physical environment, and leader- by two reviewers. To be included, studies had to (1) enroll
ship, yet they do not provide recommendations on specific older adults aged 65 or older presenting to the ED, (2) evalu-
interventions or programs for older adults seeking care in the ate an eligible intervention strategy (described later and in
ED. Many of these initiatives just described and research pri- Table S3), (3) use a randomized or quasi-experimental design
orities have focused on specific subgroups of older adults, (nonrandomized trial, case-matched controlled prospective
making it difficult to determine which strategies might be before-and-after cohort study, interrupted time series),24
most effective for the heterogeneous population typically (4) be conducted in an Organization for Economic Coopera-
seen in the ED. tion and Development (OECD) country,25 and (5) report one
In the absence of suggested interventions and facing a or more clinical or utilization outcomes of interest. Articles
growing number of older adults using Veterans Affairs included by either reviewer underwent full-text screening.
(VA) EDs, this review was performed in collaboration with
clinical and operations leaders of the Veterans Health
Data Abstraction and Analyses
Administration (VHA) with the primary goal of identifying
effective intervention strategies that could be implemented Data from published reports were abstracted into a custom-
in more than 100 EDs across the VHA system. The key ized DistillerSR database by one reviewer; a second investi-
question of this review was “How effective are emergency gator reviewed these data for accuracy, and disagreements
department (ED) interventions in improving clinical, patient were resolved by consensus or a third reviewer. Key charac-
experience, and utilization outcomes in older adults (age teristics abstracted included patient descriptors, intervention
≥65)?” Additionally, our review included both single- and characteristics, comparator, and outcomes.
multi-strategy interventions, and carefully classified individ- For this review, ED interventions included four major
ual intervention components used within these strategies. strategies: discharge planning, case management, medica-
tion safety or management, and geriatric EDs including
those that cited the 2014 Geriatric ED Guidelines.16
METHODS
Table S3 has an in-depth description of intervention strate-
This review is part of a larger report for the US VHA’s Evidence- gies and components. Reviewers classified each study by its
based Synthesis Program conducted in collaboration with VA primary intervention strategy; studies utilizing two or more
operational partners and a technical expert panel (TEP). Mem- intervention strategies were classified as “multi-strategy.”
bers of TEP were chosen for their clinical or research expertise in Detailed information about the intervention structure and
geriatric EDs and were consulted throughout the course of the individual intervention components was also abstracted.
review, specifically in finalizing research questions, reviewing the This included the timing and setting (ie, before or after
final list of included and excluded studies, contextualization of ED discharge, or both [“bridge”]); target of intervention
results, and peer review of the final report. (eg, patient, caregiver/family member, provider); mode of
JAGS MONTH 2019–VOL. 00, NO. 00 ED INTERVENTIONS FOR OLDER ADULTS 3

delivery (eg, telephone, in person); number and type of pro- strategy, individual intervention components), but there were
viders; number of planned contacts; and number of actual too few studies to conduct these analyses.
contacts. Additional details were abstracted regarding
patient-focused intervention components (eg, assessment/
screening, patient and/or caregiver education, or support) Strength of the Body of Evidence
and provider- or service-driven components (eg, referral to The strength of evidence (SOE) was assessed using the Grading
provider and/or community resources, follow-up call or of Recommendations Assessment, Development and Evaluation
visit, continuity of care/care coordination, environmental or working group (GRADE) approach.28 In brief, this approach
procedural changes in response to 2014 Geriatric ED guide- requires assessment of four domains: ROB, consistency, direct-
lines). In consultation with our stakeholders and TEP, we ness, and precision. We considered these domains qualitatively
evaluated the presence of three key intervention compo- for the primary outcomes and assigned a summary rating of
nents: assessment, referral plus follow-up, and contact both high, moderate, low, or very low SOE after evaluating using the
before and after ED discharge (“bridge” design). GRADEpro software29 and discussion by two reviewers. SOE
Two reviewers independently assessed study risk of was assessed only for outcomes considered critical to clinical or
bias (ROB) using the criteria described by the Cochrane administrative decision making: functional status, ED return
EPOC.24 Summary ROB ratings were assigned to each visit, hospital admission, and patient experience.
study: low bias (unlikely to alter the results seriously),
unclear bias (raises some doubts about the results), or high
bias (may alter the results seriously). RESULTS

Literature Flow and Included Studies

Data Synthesis and Analysis
A total of 2000 citations were identified from a combined
Primary outcomes were organized into clinical and utiliza- search of databases, reviewing bibliographies of relevant
tion outcomes. We developed summary tables to describe the review articles, and targeted searches of ClinicalTrials.gov and
key study and intervention characteristics (Tables S4-S7). All Scopus. After applying eligibility criteria, 17 articles describing
analyses were stratified by study design (randomized or 15 studies, nine randomized30–38 and six nonrandomized39–44
nonrandomized). were included (Figure 1).
We aggregated outcomes when there were at least three The literature evaluated three of the four a priori interven-
studies with the same outcome, reported at similar time points; tion strategies including case management (n = 12), discharge
for nonrandomized studies, we required adequately adjusted planning (n = 7), and medication management/medication
analyses to be reported for inclusion in quantitative syntheses. safety (n = 3). We found no studies that evaluated geriatric
When quantitative synthesis was possible, we used random EDs, including those that cited the 2014 Guidelines.16 Roughly
effects models (DerSimonian-Laird estimator with Knapp- one-half of studies (n = 7) evaluated two or more intervention
Hartung SE adjustment26,27) to synthesize dichotomous out- strategies and were classified as multi-strategy. Studies were
comes (ie, hospitalization at or after the ED index visit, ED also evaluated for three key patient-focused intervention com-
return visit) using risk ratios, and the mean difference ponents including assessment (n = 12, 8 of which specified use
(MD) for continuous outcomes (ie, quality of life [QOL]). We of a comprehensive geriatric assessment), referral plus follow-
evaluated statistical heterogeneity using visual inspection and up (n = 6), and contact both before and after ED discharge,
Cochran’s Q and I2 statistics. There were too few studies to defined as a bridge design (n = 5). Studies that included all
assess publication bias with test statistics. We planned formal three key intervention components were classified as having a
subgroup analyses of moderator variables (eg, intervention more comprehensive structure (n = 4).33,34,36,37 Additional

Figure 1. Literature flow diagram. Asterisk indicates unique citations after combining all searches and manual bibliography review.
4 HUGHES ET AL. MONTH 2019–VOL. 00, NO. 00 JAGS

details of the 15 included studies, including characteristics of Functional status was assessed differently across the stud-
study participants, is shown in Table 1. Additional details of ies. Three randomized studies defined functional status as
the included intervention components are included in Tables S6 changes in dependence in activities of daily living (ADLs) or
and S7. instrumental activities of daily living (IADLs).34,36,38 One
multi-strategy study, using discharge planning plus case man-
agement and one key intervention component, found a statisti-
cally significant lower odds of clinically important functional
Effects on Clinical Outcomes dependency (odds ratio [OR] = .53; 95% CI = .31-.91) at
3 and 4 months, respectively.36 A second multi-strategy study,
Functional Status
also utilizing discharge planning plus case management and
Six studies, five randomized, evaluated the effect of ED one key intervention component, found a significantly greater
interventions on functional status, assessed from 1 to odds of functional improvement, as defined by improvement
18 months after the ED visit.33–36,38,42 Three studies evalu- in ADL performance measured at 3 months (OR = 2.37; 95%
ated multi-strategy interventions, all using discharge plan- CI = 1.20-4.68) and 12 months (OR = 2.04; 95% CI =
ning plus case management,34,36,42 two of which included 1.03-4.06).34 A third single-strategy study of case management
all three intervention components of interest.34,36 Positive involving one key intervention component found that interven-
intervention effects were observed in four of the five ran- tion participants reported higher levels of functional indepen-
domized studies.33,34,36,38 dence in IADLs compared with the control group (P = .027),

Table 1. Evidence Profile for Emergency Department Interventions for Older Adults

Randomized (n = 9) Nonrandomized (n = 6)

Study designs 8 randomized studies 5 nonrandomized studies

1 cluster-randomized study 1 controlled before-after study
No. of patients 4561 11 580
Patient eligibilitya 4 high-risk patients only 4 high-risk patients only
5 unselected older adults 2 unselected older adults
Exclusion criteria 3 need for immediate treatment 3 need for immediate treatment
6 long-term care facility 0 long-term care facility
5 cognitive impairment 1 cognitive impairment
Median patient age (range) 79 (74-82) 78.5 (75-86)
(1 study NR)
Patient sex, % 59% women 59% women
Race, % 64% white (6 studies NR) 67% white (5 studies NR)
25% black 32% black
Patients with cognitive impairmentb 27.3% (5 studies NR) 8.5% (5 studies NR)
Patients’ living status (%) 789/4688 (16.8%) living alone 3072/11 580 (26.5%) living alone
(5 studies NR) (2 studies NR)
Patient has primary carec 88% (8 studies NR) NR
Intervention strategyd 3 discharge planning 4 discharge planning
9 case management 3 care management
2 medication safety 1 medication management
0 geriatric EDs 0 geriatric EDs
Multi-strategy interventions 5 studies 2 studies
Key intervention componentsd 7 assessment 5 assessment
5 referral plus follow-up 1 referral plus follow-up
4 bridge designe 1 bridge designe
Outcomes reported 7 ED readmission 5 ED readmission
6 functional status 1 functional status
5 hospitalization after ED discharge 3 hospitalization after ED discharge
4 patient experience 1 patient experience
2 quality of life 1 quality of life
2 hospitalization at ED index 2 hospitalization at ED index
Risk of bias for objective and patient-reported Objective: Patient-reported: Objective: Patient-reported:
outcomes 2 high risk 4 high risk 5 high risk 2 high risk
3 unclear risk 3 unclear risk 1 low risk 4 NA
3 low risk 2 low risk
1 NA

Abbreviation: ED = emergency department; NA = not applicable; NR = not reported.

a
High-risk is defined by the study authors based on risk assessment tool and/or specific criteria or condition(s).
b
Definitions of impairment varied from abnormal cognitive screen to dementia to delirium/confusion.
c
Six randomized and five nonrandomized studies were conducted in countries with National Health Service.
d
Numbers sum to more than 15 because studies used more than one intervention type.
e
Design refers to interventions that include contact both within the ED and after discharge.
JAGS MONTH 2019–VOL. 00, NO. 00 ED INTERVENTIONS FOR OLDER ADULTS 5

but there were no significant differences in ADL independence Effects on Utilization Outcomes
(P = .47).38 One nonrandomized multi-strategy study of dis-
charge planning plus case management included only one key Hospitalization at the ED Index Visit
intervention component and examined the number of older
Four studies, two randomized, examined the effect of ED inter-
adults reporting basic and intermediate dependency in ADLs ventions on hospitalization at the index ED visit.30,36,39,41
based on the Katz scale.42 Although no statistical tests were Overall, there was no pattern of interventions on hospitaliza-
presented, the number of participants reporting each level of tion at the index visit. Only one study included all three inter-
dependency at 3 months was similar for the intervention and vention components, with very few patients admitted at the
control groups. index visit because one of the inclusion criteria was an expecta-
Two randomized studies of case management interven- tion that the patient would be discharged from the ED.36 One
tions evaluated change in functional status as a continuous single-strategy intervention that utilized only one of the key
outcome.33,35 The first study included one key intervention intervention components found that a subset of patients who
component and recruited a high-risk population of older received the discharge planning intervention had a lower rate
adults who had been admitted to the hospital in the prior of admission.39 This was a large nonrandomized study that
12 months.35 There were no differences in ADL or IADL was judged high ROB.
mean scores between groups. A second study included all
three key intervention components and found that interven-
tion participants reported less functional decline at 6 months Hospitalization after the ED Index Visit
compared with control (−.25 intervention vs −.75 control; Nine studies, five randomized, reported effects of ED interven-
P < .001),33 although there were no significant differences tions on hospitalization after the index ED visit.31–33,35,37,38,40–42
between groups at 18 months. Five evaluated multi-strategy interventions,31,32,37,41,42 two of
which included all three intervention components.33,37
Six studies, three randomized, reported hospitalization as a
Quality of Life
dichotomous outcome.32,33,37 Overall, there was no interven-
Two randomized studies evaluated multi-strategy interven- tion effect for the randomized studies (relative risk [RR] = .96;
tions of discharge planning plus case management on 95% CI = .51-1.83; Figure 2), but the CI was wide, and inter-
QOL.35,37 Both studies reported physical and mental vention effects varied significantly (Q = 5.4; P = .07; I2 = 63%).
health–related QOL using the Short Form-36 physical func- Two studies had prolonged follow-up periods of 120 days and
tion and mental health component scores at 3037 and 18 months,33,37 with one finding a decreased risk of hospitaliza-
120 days.35 There were no statistically significant effects of tion at each of the follow-up time points.33 This study was a
the ED interventions on either physical or mental health– single-strategy case management intervention with all three key
related QOL at any time point. There were not sufficient data intervention components.33 Another study evaluated case man-
reported in one nonrandomized study42 to conduct an analy- agement and included all three intervention components.44 This
sis. However, scores were similar for intervention and con- study found a lower likelihood of hospitalization at 30 days
trol participants. (RR = .55; 95% CI = .36-.82). A high ROB study that evalu-
ated discharge planning and included only one intervention
component, assessment, found that intervention participants
Effects on Patient Experience Outcomes had a higher risk of hospitalization at 1 year.40 The matching
used for this study involved matching a high-risk intervention
Four randomized studies evaluated the effect of ED inter- participant with a low-risk control participant.
ventions on patient experience using a range of outcome Three randomized studies reported hospitalization after
measures; effects were mixed.35–38 Two studies evaluated the ED index visit using a variety of continuous outcome
multi-strategy interventions of discharge planning plus case measures.33,35,37 Only one study, which used all three inter-
management, and they included all three intervention com- vention components, found a significant effect of the inter-
ponents of interest.36,37 Overall, these studies show a mixed vention on hospitalization after the ED index, with a
pattern, with one single-strategy and one multi-strategy reported number needed to treat of 18 to prevent one hos-
study reporting higher satisfaction with care or greater pitalization at 30 days, and a number needed to treat of
patient knowledge of community resources.37,38 10 to prevent one hospital admission at 18 months.33
Two studies, one using case management and the second
discharge planning plus case management, evaluated patient
satisfaction with care using continuous outcome measures, Emergency Department Return Visit
the Client Satisfaction Questionnaire and Satisfaction with Twelve studies, seven randomized, reported on return visits
Care Scale.35,36 Assessment time points occurred at 1 and to the ED after the initial index ED visit.31–33,35–38,40–44 Six
10 months. There were no statistically significant effects on studies evaluated multi-strategy interventions.31,32,36,37,41,42
patient experience in either study. A third study37 found All three intervention components were present in three
higher satisfaction among intervention participants regarding randomized studies33,36,37 and one nonrandomized study.42
information received in the ED on postdischarge support ser- When considered together, the randomized studies
vices (3.42 vs 3.03; MD = .37; 95% CI = .13-.62). A fourth reporting ED return visit(s) as a dichotomous outcome
study evaluating case management utilized an unnamed instru- found no effect on ED return visit(s) (RR = 1.13; 95% CI =
ment and found that 40% of intervention participants recalled .94-1.36; Figure 3).31–33,37,38 A single low ROB study
helpful information, and 28% reported benefits of improved (n = 345) found that a multi-strategy intervention that used
confidence and self-esteem.38 all three key components led to an increased risk of ED
6 HUGHES ET AL. MONTH 2019–VOL. 00, NO. 00 JAGS

Figure 2. Forest plot for effect of emergency department interventions on hospitalization after the index visit.
CI = confidence interval; DC = discharge; ED = emergency department.

Figure 3. Forest plot for effect of emergency department interventions on emergency department return visit.
CI = confidence interval; DC = discharge; ED = emergency department.

return visit(s) at 30 days.36 In a post hoc stratified analysis, management strategy, with two of the three key interven-
this effect was seen only in patients who had not visited tion components, found that risk of ED return visit(s) fol-
their primary care physician in the month before the ED lowing an intervention was decreased (hazard ratio = .49;
index visit. There was also no effect of interventions on ED 95% CI = .33-.72).44 In this study, a higher percentage of
return visit(s) when measured as a continuous variable participants in the intervention group were discharged to
including both number of hospitalizations and mean length home at the index ED visit and had more prompt follow-up
of stay at 10-month follow-up.35 and/or a longer length of sustained contact with the geriat-
Four nonrandomized studies reported ED return visit(s) ric team. Another study evaluating a discharge planning
as a dichotomous variable,40,41,43,44 one of which evaluated intervention, with only assessment as a key component,
a multi-strategy intervention.41 One study that used a case found the risk of ED return visit(s) to be increased (risk
JAGS MONTH 2019–VOL. 00, NO. 00 ED INTERVENTIONS FOR OLDER ADULTS 7

difference 3%; P = .05) following receipt of the interven-

tion.40 In this study, control case matches were low-risk
Strength of evidence (rationale by domain)
participants while those in the intervention group were

(No serious ROB, inconsistent, imprecise)

deemed to be high risk. A fifth nonrandomized study
(Serious ROB, inconsistent, imprecise)

(No serious ROB, consistent, precise)

(No serious ROB, consistent, indirect,

reported the number of ED visits within a 3-month follow-
up period but found no difference between groups.42

Quality of Evidence
ROB is described for the nine randomized studies in
Figure S2. We separately evaluated objective outcomes (eg,
ED return visit or visits) and patient-reported, or subjective,
Very low SOE

outcomes (eg, QOL). For objective outcomes, we judged six

imprecise)
High SOE

Low SOE

Low SOE of the nine studies as low or unclear ROB. For patient-
reported outcomes, five of nine studies were judged low or
Table 2. Strength of Evidence for Effects of Interventions to Improve Outcomes for Older Adults in Emergency Departments

unclear ROB. Factors that led to higher ROB judgments

included unclear randomization and allocation conceal-
ment, detection bias (patient-reported outcomes), and dif-
ferences in baseline patient characteristics.
We judged five of the six nonrandomized studies
(Figure S3) as high ROB for objective outcomes and one as
3 of 5 showed benefit; beneficial interventions

low ROB.44 Because the EPOC quality criteria consider

2 of 5 showed lower readmission; beneficial

random sequence generation even for nonrandomized

interventions were multi-strategy or case

interventions were multi-strategy or case

designs, this was a major factor in the high ROB ratings.

2 of 4 showed benefit for satisfaction,
helpfulness or self-esteem; beneficial
No consistent effects on readmission

Other concerns were lack of proof that baseline provider

(59 fewer to 100 more per 1000)

characteristics (eg, experience) were similar, and lack of

(9 fewer to 53 more per 1000)

proof that baseline outcome measurements were similar.

Findings

Relative risk 1.13 (.94-1.36)

Relative risk .96 (.51-1.83)

Also, many studies had fundamental differences in baseline

patient characteristics that may affect outcomes.
We rated SOE for outcomes judged critical to decision
were multi-strategy

making on the basis of study design, ROB, consistency,

No usable data

directness, and precision (Table 2). The SOE was rated high
management

management

for effects on ED return visit(s). SOE was low or very low

No effect

for all other outcomes. Concerns that contributed to the

lower SOE were high ROB, inconsistent effects, and impre-
cision that was attributed to the 95% CI not excluding a
Abbreviation: ED = emergency department; ROB = risk of bias; SOE = strength of evidence.

small or small to moderate effect.

DISCUSSION
Nonrandomized: 5 (6432)

Nonrandomized: 3 (5346)
Nonrandomized: 1 (687)

Nonrandomized: 1 (199)

This review evaluated the effect of ED intervention strate-

Randomized: 5 (2233)

Randomized: 7 (4629)

Randomized: 3 (3338)

Randomized: 4 (1889)

gies for older adults on a range of outcomes. Our review is

Studies (patients)

unique in the approach to classifying intervention strategies

and individual intervention components, careful ROB
assessment, and the inclusion of randomized and more rig-
orous quasi-experimental designs. When considering the
interventions collectively, we found a small benefit on func-
tional status but no overall effect on ED return visit(s) or sub-
sequent hospitalization. Although there was no overall effect
on healthcare utilization, two studies with a more comprehen-
sive intervention (ie, all three intervention components present)
and longer duration of follow-up were associated with
Hospital admission after index

decreased ED return visits and hospitalization after the index

ED visit.33,44 Other outcomes were reported less frequently,
and intervention effects could not be determined definitively.
Overall, the small number of included studies, the hetero-
Patient experience
Physical function

geneity of study designs, and the incomplete details pro-

ED readmission

vided around individual intervention components

prevented us from drawing definitive conclusions about
the effectiveness of any one specific intervention strategy.
Outcome

Key takeaway messages are listed in Table 3. Some of the

review’s strengths and limitations are described next.
8 HUGHES ET AL. MONTH 2019–VOL. 00, NO. 00 JAGS

Table 3. Key Implications of Review

Clinical implications • Conducting a comprehensive geriatric assessment may be useful in identifying patients’ needs and
areas for intervention
• Interventions that bridge care occurring before and after ED discharge may be associated with
better outcomes
Research implications • Additional research is needed to identify appropriate outcome measures that are sensitive to
change and can be utilized across different studies
• Quality improvement initiatives may represent an important aspect of research, revealing important
findings within real-world settings
Policy implications • Further specificity around the 2014 Geriatric ED Guidelines, including consistent terminology,
may be beneficial
• Patients, caregivers, providers, and other key stakeholders should be involved in guiding
future research agendas

Rather than focusing narrowly on condition-specific informative evidence. In an effort to identify ED strategies
interventions (eg, geriatric falls, heart failure), we evaluated conducted in similar healthcare environments and/or sys-
interventions applicable to a broad range of older adults. tems as the United States, we elected to include only those
We were particularly interested in determining if specific studies conducted in an OECD country. However, this may
strategies or intervention components were associated with have prevented inclusion of rigorous studies published in
greater benefit to older adults. Two strategies were evalu- other countries.
ated infrequently (medication management) or not at all Variations in basic study design and the lack of ana-
(geriatric EDs). Interventions evaluated were relatively low lyses that adjust for potential confounders were common
intensity (ie, short duration and limited number of planned problems. Diversity across study designs and intervention
patient contacts), and thus our findings are applicable only characteristics (ie, strategies, components, delivery, and
to low-intensity geriatric management interventions in the intensity) made coherent synthesis and identification of
ED. Although the use of more than one strategy or a more themes difficult. We were often limited in our ability to fully
comprehensive intervention structure (ie, a higher number abstract details of individual intervention components
of patient-centered intervention components) may be associ- because few studies provided in-depth descriptions of the
ated with better outcomes, the relative benefit of individual interventions. Also, the studies identified did not apply a
intervention strategies and components is unclear and consistent conceptual model hypothesizing the relationship
requires further research. between intervention strategies and outcomes; nor did stud-
In contrast to prior reviews that focused on single ies follow a set of clinical recommendations or guidelines,
strategies,2,9,10,12 our review included studies with multiple such as the 2014 Geriatric ED Guidelines,16 to inform inter-
intervention strategies. Only one of the prior systematic vention structure.
reviews was published in the past 5 years (search date We acknowledge that the lack of studies that reference
2013; number of studies = 9) and evaluated discharge plan- the 2014 Guidelines likely has to do with the short time
ning; the findings of this good-quality review were consis- frame from the publication and the length of time required
tent with our results.12 Also similar to findings from our to obtain funding, execute a study, conduct analyses, and
review, another review of case management found that publish results. Overall, we were limited by the quality of
these interventions did not impact QOL, although the and consistency in the existing literature. Of the nine ran-
amount of evidence for this outcome was sparse.2 Across domized studies, only three were evaluated as low ROB for
these reviews, general themes are that more comprehensive objective outcomes. The most common limitation was lack
interventions and those using multiple strategies are associ- of blinded outcomes assessment. Almost all nonrandomized
ated with greater effects but that interventions tested to date studies were judged high ROB for both objective and
do not show a consistent effect on utilization outcomes. patient-reported outcomes. Finally, we were unable to rule
Similar to previous reviews45 and the 2014 Geriatric Emer- out publication bias; given the small number of studies, sta-
gency Department Guidelines,16 our finding that bridge tistical methods to detect publication bias are not useful.
designs may be associated with positive outcomes suggests
that ED visits should not be considered in isolation but
rather as an integral part of the older patient’s continuum Future Directions
of care, bridging inpatient and outpatient services.
As the number of older adults continues to rise, and as EDs
continue to provide frequent care for this population’s com-
plex needs, it is critical that future research be conducted to
Limitations
identify best practices including intervention strategies. We
Our protocol-driven review has several strengths, specifi- believe future research may benefit from the following con-
cally the use of rigorous methods including input from an siderations. First, the use of a conceptual model may
expert panel, use of a conceptual model, and a structured encourage researchers to consider the multilevel factors that
approach to describing the key strategies and components influence ED use (eg, sociodemographic factors, clinical and
of the tested interventions. Despite these strengths, we note individual characteristics, access to services), complex inter-
several limitations. We limited our review to English- vention strategies, and outcomes of interest, plus the rela-
language publications that may have excluded potentially tionship among these factors. Second, the use of innovative
JAGS MONTH 2019–VOL. 00, NO. 00 ED INTERVENTIONS FOR OLDER ADULTS 9

intervention designs, such as adaptive trials (eg, stepped care), Primary Care (CIN 13-410) at the Durham VA Health Care
and sophisticated study designs, such as pragmatic trials, may System. We would like to thank Liz Wing, MA; Avishek Nagi,
enable researchers to accommodate the heterogeneity of older MS; Jennifer McDuffie, PhD; and Megan Van Noord, MSIS,
adult patients while isolating and evaluating the effects of indi- for their assistance with this project.
vidual intervention components within real-world settings. Financial Disclosure: US Department of Veterans
Third, careful selection of measures that are both appropriate Affairs (PROSPERO: CRD42018087660).
for a heterogeneous population and responsive to change is Conflict of Interest: The authors have declared no con-
critical. Developing common measures to be used across stud- flicts of interest for this article.
ies may also help advance the field, as has been done within Author Contributions: Jaime M. Hughes, Caroline
other geriatric research areas.46 E. Freiermuth, and John W. Williams contributed to the
The field of geriatric emergency medicine continues to study design and first draft of the manuscript. All study
evolve rapidly. For instance, between the conclusion of our authors were involved in data abstraction, interpretation of
search and the peer review process of this article, an array of results, and review of the final draft of this manuscript.
studies were published including a review of self-defined geri- Sponsor’s Role: This project and the Durham VA ESP
atric EDs,47 a nurse transition intervention,48 and a prag- are funded by the US Department of Veterans Affairs that
matic trial of an Australian-based geriatric ED.49 Ongoing had no involvement in data collection, analysis, interpreta-
research is likely to result in additional articles in the near tion of the results, or the decision to submit this manu-
future, as evidenced by scientific abstracts presented at recent script. The views expressed in this article are those of the
scientific meetings. Additionally, in a targeted search of authors and do not necessarily reflect the position or policy
ClinicalTrials.gov, we found eight active studies focused on of the Department of Veterans Affairs, the US government,
older adults in the ED. Of note, none of these studies evalu- or Duke University.
ated intervention strategies to be used with a general older
adult population.
The 2014 Guidelines offer recommendations across a REFERENCES
number of domains (eg, staffing, administration, clinical pro-
1. Rui P, Kang K. National hospital ambulatory medical care survey: 2014
cedures) and may, in combination with a theory-informed emergency department summary tables. https://www.cdc.gov/nchs/ahcd/web_
conceptual model, inform future studies. It is our experience tables.htm. Accessed June 21, 2018.
that health systems often implement changes and measure 2. Sinha SK, Bessman ES, Flomenbaum N, Leff B. A systematic review and
their effects on an internal basis for quality improvement pur- qualitative analysis to inform the development of a new emergency
department-based geriatric case management model. Ann Emerg Med. 2011;
poses. We would encourage health systems to design their eval- 57:672-682.
uation of implemented change in such a way that it can be 3. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a sys-
published for wider distribution and affect change on a large tematic review of patterns of use, adverse outcomes, and effectiveness of
scale. Finally, future research may benefit from working across interventions. Ann Emerg Med. 2002;39:238-247.
4. Keim S, Sanders A. Geriatric emergency department use and care. In:
settings and disciplines, and from incorporating feedback from Meldon S, Ma OJ, Woolard R, eds. Geriatric Emergency Medicine.
patients, care partners, and key stakeholders representing both New York, NY: McGraw-Hill; 2004:1-3.
ED and post-ED settings. 5. Sanders AB, Morley JE. The older person and the emergency department.
In conclusion, our results indicate mixed effects of ED J Am Geriatr Soc. 1993;41:880-882.
6. Baum SA, Rubenstein LZ. Old people in the emergency room: age-related
intervention strategies on select clinical and utilization out-
differences in emergency department use and care. J Am Geriatr Soc. 1987;
comes for older adults. In contrast to the growing number of 35:398-404.
older adults visiting the ED, we found a surprisingly small 7. Grief CL. Patterns of ED use and perceptions of the elderly regarding their
number of studies evaluating geriatric ED interventions. The emergency care: a synthesis of recent research. J Emerg Nurs. 2003;29:
limited number of studies using any single intervention strat- 122-126.
8. Preston LR, Chambers D, Campbell F, Cantrell A, Turner J, Goyder E. What
egy makes it difficult to draw definitive conclusions because evidence is there for the identification and management of frail older people
of imprecise estimates of effect and variability in study popu- in the emergency department? A systematic mapping review. National Insti-
lations, intervention strategies, and intervention compo- tute for Health Research. Southampton, UK: Queen’s Printer and Controller
nents. However, we found evidence that individual studies of HMSO; April 2018.
9. Conroy SP, Stevens T, Parker SG, Gladman JR. A systematic review of com-
evaluating multi-strategy interventions and those with a prehensive geriatric assessment to improve outcomes for frail older people
more comprehensive structure, as indicated by the presence being rapidly discharged from acute hospital: “interface geriatrics”. Age Age-
of three key intervention components, may be associated ing. 2011;40:436-443.
with a small benefit in functional status, decreased hospitali- 10. Fealy G, McCarron M, O’Neill D, et al. Effectiveness of gerontologically
informed nursing assessment and referral interventions for older persons
zation after the ED index visit, and a lower likelihood of ED
attending the emergency department: systematic review. J Adv Nurs. 2009;
return visit(s). 65:934-935.
11. Jay S, Whittaker P, McIntosh J, Hadden N. Can consultant geriatrician led
comprehensive geriatric assessment in the emergency department reduce hos-
ACKNOWLEDGMENTS pital admission rates? A systematic review. Age Ageing. 2017;46:366-372.
12. Lowthian JA, McGinnes RA, Brand CA, Barker AL, Cameron PA. Dischar-
This article is based on research conducted by the Evidence- ging older patients from the emergency department effectively: a systematic
based Synthesis Program (ESP) Center located at the Durham review and meta-analysis. Age Ageing. 2015;44:761-770.
VA Medical Center, Durham, NC, funded by the Depart- 13. GEDI Wise Investigators, Adams J, Adinaro D, et al. GEDI WISE: geriatric
ment of Veterans Affairs, Veterans Health Administration, emergency department innovations in care through workforce, informatics,
and structural enhancements. Ann Emerg Med. 2013;62:S54-S55.
and Office of Research and Development, Quality Enhance- 14. Carpenter CR, Heard K, Wilber S, et al. Research priorities for high-quality
ment Research Initiative. This work was also supported by geriatric emergency care: medication management, screening, and prevention
the Center of Innovation for Health Services Research in and functional assessment. Acad Emerg Med. 2011;18:644-654.
10 HUGHES ET AL. MONTH 2019–VOL. 00, NO. 00 JAGS

15. Carpenter CR, Shah MN, Hustey FM, Heard K, Gerson LW, Miller DK. 37. Mion LC, Palmer RM, Meldon SW, et al. Case finding and referral model
High yield research opportunities in geriatric emergency medicine: prehospi- for emergency department elders: a randomized clinical trial. Ann Emerg
tal care, delirium, adverse drug events, and falls. J Gerontol A Biol Sci Med Med. 2003;41:57-68.
Sci. 2011;66A:775-683. 38. Runciman P, Currie CT, Nicol M, Green L, McKay V. Discharge of elderly
16. American College of Emergency Physicians, American Geriatrics Society, people from an accident and emergency department: evaluation of health vis-
Emergency Nurses Association, Society for Academic Emergency Medicine, itor follow-up. J Adv Nurs. 1996;24:711-718.
Geriatric Emergency Department Guidelines Task Force. Geriatric emergency 39. Arendts G, Fitzhardinge S, Pronk K, Donaldson M, Hutton M, Nagree Y.
department guidelines. Ann Emerg Med. 2014;63:e7-e25. The impact of early emergency department allied health intervention on
17. Carpenter CR, Bromley M, Caterino JM, et al. Optimal older adult emer- admission rates in older people: a non-randomized clinical study. BMC Ger-
gency care: introducing multidisciplinary geriatric emergency department iatr. 2012;12:8.
guidelines from the American College of Emergency Physicians, American 40. Arendts G, Fitzhardinge S, Pronk K, Hutton M. Outcomes in older patients
Geriatrics Society, emergency nurses association, and Society for Academic requiring comprehensive allied health care prior to discharge from the emer-
Emergency Medicine. Acad Emerg Med. 2014;21:806-809. gency department. Emerg Med Australas. 2013;25:127-131.
18. Carpenter CR, Bromley M, Caterino JM, et al. Optimal older adult emer- 41. Bond CM, Freiheit EA, Podruzny L, et al. The emergency to home project:
gency care: introducing multidisciplinary geriatric emergency department impact of an emergency department care coordinator on hospital admission
guidelines from the American College of Emergency Physicians, American and emergency department utilization among seniors. Int J Emerg Med.
Geriatrics Society, emergency nurses association, and Society for Academic 2014;7:18.
Emergency Medicine. J Am Geriatr Soc. 2014;62:1360-1363. 42. Miller DK, Lewis LM, Nork MJ, Morley JE. Controlled trial of a geriatric
19. Carpenter CR, Bromley M, Caterino JM, et al. Optimal older adult emer- case-finding and liaison service in an emergency department. J Am Geriatr
gency care: introducing multidisciplinary geriatric emergency department Soc. 1996;44:513-520.
guidelines from the American College of Emergency Physicians, American 43. Mortimer C, Emmerton L, Lum E. The impact of an aged care pharmacist in
Geriatrics Society, emergency nurses association, and Society for Academic a department of emergency medicine. J Eval Clin Pract. 2011;17:478-485.
Emergency Medicine. Ann Emerg Med. 2014;63:e1-e3. 44. Pedersen LH, Gregersen M, Barat I, Damsgaard EM. Early geriatric follow-
20. Pines JM, Lotrecchiano GR, Zocchi MS, et al. A conceptual model for epi- up after discharge reduces readmissions—a quasi-randomised controlled
sodes of acute, unscheduled care. Ann Emerg Med. 2016;68:484-491. e3. trial. Eur Geriatr Med. 2016;7:443-448.
21. Gruneir A, Silver MJ, Rochon PA. Emergency department use by older 45. Karam G, Radden Z, Berall LE, Cheng C, Gruneir A. Efficacy of emergency
adults: a literature review on trends, appropriateness, and consequences of department-based interventions designed to reduce repeat visits and other
unmet health care needs. Med Care Res Rev. 2011;68:131-155. adverse outcomes for older patients after discharge: a systematic review. Ger-
22. Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital iatr Gerontol Int. 2015;15:1107-1117.
readmissions: a systematic review and meta-analysis of randomized trials. 46. Working Group on Health Outcomes for Older Persons with Multiple
JAMA Intern Med. 2014;174:1095-1107. Chronic Conditions. Universal health outcome measures for older persons
23. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to with multiple chronic conditions. J Am Geriatr Soc. 2012;60:2333-2341.
reduce 30-day hospitalization: a systematic review. Ann Intern Med. 2011; 47. Schumacher JG, Hirshon JM, Magidson P, Chrisman M, Hogan T. Tracking
155:520-528. the rise of geriatric emergency departments in the United States. J Appl Geron-
24. Effective Practice and Organisation of Care (EPOC). EPOC Resources for tol. 2018; 0733464818813030. https://doi.org/10.1177/0733464818813030
Review Authors. Oslo, Norway: Norwegian Knowledge Centre for the 48. Hwang U, Dresden SM, Rosenberg MS, et al. Geriatric emergency depart-
Health Services; 2015. http://epoc.cochrane.org/resources/epoc-resources- ment innovations: transitional care nurses and hospital use. J Am Geriatr
review-authors. Accessed November 3, 2017. Soc. 2018;66:459-466.
25. List of OECD member countries—ratification of the convention on the 49. Wallis M, Marsden E, Taylor A, et al. The geriatric emergency department
OECD. http://www.oecd.org/about/membersandpartners/list-oecd-member- intervention model of care: a pragmatic trial. BMC Geriatr. 2018;18:297.
countries.htm. Accessed November 3, 2017.
26. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials.
1986;7:177-188.
27. Knapp G, Hartung J. Improved tests for a random effects meta-regression
SUPPORTING INFORMATION
with a single covariate. Stat Med. 2003;22:2693-2710.
Additional Supporting Information may be found in the
28. Balshem H, Helfand M, Schunemann HJ, et al. GRADE guidelines: 3. Rating
the quality of evidence. J Clin Epidemiol. 2011;64:401-406. online version of this article.
29. GRADEpro GDT. GRADEpro Guideline Development Tool [software].
McMaster University, 2015 (developed by Evidence Prime, Inc.). gradepro.org. Table S1. Search Strategy.
30. Basic D, Conforti DA. A prospective, randomised controlled trial of an aged
care nurse intervention within the emergency department. Aust Health Rev.
Table S2. Study Eligibility Criteria.
2005;29:51-59. Table S3. Classification of ED Intervention Strategies and
31. Biese K, Lamantia M, Shofer F, et al. A randomized trial exploring the effect Intervention Components.
of a telephone call follow-up on care plan compliance among older adults Table S4. Characteristics of Randomized Studies.
discharged home from the emergency department. Acad Emerg Med. 2014;
21:188-195.
Table S5. Characteristics of Nonrandomized Studies.
32. Biese KJ, Busby-Whitehead J, Cai J, et al. Telephone follow-up for older Table S6. Intervention Characteristics of Randomized Studies.
adults discharged to home from the emergency department: a pragmatic ran- Table S7. Intervention Characteristics of Nonrandomized
domized controlled trial. J Am Geriatr Soc. 2018;66:452-458. Studies.
33. Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled
trial of comprehensive geriatric assessment and multidisciplinary intervention
Figure S1. Conceptual model.
after discharge of elderly from the emergency department—the DEED II Figure S2. Risk of bias ratings for randomized studies. White
study. J Am Geriatr Soc. 2004;52:1417-1423. indicates items that were not applicable. Green/positive indi-
34. Eklund K, Wilhelmson K, Gustafsson H, Landahl S, Dahlin-Ivanoff S. One- cates items that were judged low ROB. Yellow/question mark
year outcome of frailty indicators and activities of daily living following the
randomised controlled trial: “continuum of care for frail older people”.
indicates items that were judged unclear ROB. Red/negative
BMC Geriatr. 2013;13:76. indicates items that were judged high ROB.
35. Gagnon AJ, Schein C, McVey L, Bergman H. Randomized controlled trial of nurse Figure S3. Risk of bias ratings for nonrandomized studies.
case management of frail older people. J Am Geriatr Soc. 1999;47:1118-1124. White indicates items that were not applicable. Green/positive
36. McCusker J, Verdon J, Tousignant P, de Courval LP, Dendukuri N,
Belzile E. Rapid emergency department intervention for older people reduces
indicates items that were judged low ROB. Yellow/question
risk of functional decline: results of a multicenter randomized trial. J Am mark indicates items that were judged unclear ROB.
Geriatr Soc. 2001;49:1272-1281. Red/negative indicates items that were judged high ROB.