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Memedovich A, Asante B, Khan M, Eze N, Holroyd BR, Lang E, Kashuba S, Clement F. Strategies for improving ED-related outcomes of older adults who seek care in emergency departments: a systematic review. Int J Emerg Med 2024; 17:16. [PMID: 38302890 PMCID: PMC10835906 DOI: 10.1186/s12245-024-00584-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/12/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Despite constituting 14% of the general population, older adults make up almost a quarter of all emergency department (ED) visits. These visits often do not adequately address patient needs, with nearly 80% of older patients discharged from the ED carrying at least one unattended health concern. Many interventions have been implemented and tested in the ED to care for older adults, which have not been recently synthesized. METHODS A systematic review was conducted to identify interventions initiated in the ED to address the needs of older adults. Embase, MEDLINE, CINAHL, Cochrane CENTRAL, the Cochrane Database of Systematic Reviews, and grey literature were searched from January 2013 to January 18, 2023. Comparative studies assessing interventions for older adults in the ED were included. The quality of controlled trials was assessed with the Cochrane risk-of-bias tool for randomized trials, and the quality of observational studies was assessed with the risk of bias in non-randomized studies of interventions tool. Due to heterogeneity, meta-analysis was not possible. RESULTS Sixteen studies were included, assessing 12 different types of interventions. Overall study quality was low to moderate: 10 studies had a high risk of bias, 5 had a moderate risk of bias, and only 1 had a low risk of bias. Follow-up telephone calls, referrals, geriatric assessment, pharmacist-led interventions, physical therapy services, care plans, education, case management, home visits, care transition interventions, a geriatric ED, and care coordination were assessed, many of which were combined to create multi-faceted interventions. Care coordination with additional support and early assessment and intervention were the only two interventions that consistently reported improved outcomes. Most studies did not report significant improvements in ED revisits, hospitalization, time spent in the ED, costs, or outpatient utilization. Two studies reported on patient perspectives. CONCLUSION Few interventions demonstrate promise in reducing ED revisits for older adults, and this review identified significant gaps in understanding other outcomes, patient perspectives, and the effectiveness in addressing underlying health needs. This could suggest, therefore, that most revisits in this population are unavoidable manifestations of frailty and disease trajectory. Efforts to improve older patients' needs should focus on interventions initiated outside the ED.
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Affiliation(s)
- Ally Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Benedicta Asante
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Maha Khan
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Nkiruka Eze
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Brian R Holroyd
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Eddy Lang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - Sherri Kashuba
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada.
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Langlois H, Proulx LC, Villeneuve É, Adam JP. Impact of Postgraduate Second-Year Pharmacy Training (PGY2) on Clinical, Financial, and Educational Outcomes: A Scoping Review. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2023; 87:100037. [PMID: 37597915 DOI: 10.1016/j.ajpe.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 08/16/2022] [Accepted: 08/23/2022] [Indexed: 08/21/2023]
Abstract
OBJECTIVE A scoping review was conducted to screen the published literature on the clinical, financial, and educational effect of postgraduate second year (PGY2) pharmacy residency training. FINDINGS A search strategy was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Central and Web of Science without study design, language, or time restrictions (inception to March 2022). Articles were reported using the PRISMA reporting items list. Studies were included if a measurable clinical outcome, a cost-avoidance calculation and/or involvement in teaching or research activities was reported. Studies were excluded if there was no mention of a PGY2 training. Of the 2534 articles that were screened, 21 articles met our inclusion criteria. Seven studies reported clinical outcomes, five reported cost avoidance, six reported educational outcomes and three studies reported both clinical and cost-avoidance outcomes. Four of the studies evaluating clinical outcomes took place in a psychiatric clinic setting. Better disease control was reported in four articles. Two studies evaluated readmission and emergency department visits at 30 days but only one showed significant reduction. The estimated cost avoidance reported ranged from $22,380 to $5,387,679 and two studies reported the services billed by the resident. In two studies, PGY2 pharmacists were more likely to be involved in teaching activities and were more likely to participate in research activities. CONCLUSION Even though few studies evaluated the benefits of PGY2 pharmacy trainings, they showed to improve patient care, enhance involvement in teaching activities, and decrease financial burden for health-care systems. More studies should be done to reinforce the merits of such training.
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Affiliation(s)
- Hugo Langlois
- Faculty of Medicine, Université de Montréal, Montréal, Canada
| | | | - Éric Villeneuve
- Pharmacy Department, McGill University Health Centre, Montreal, Canada
| | - Jean-Philippe Adam
- Pharmacy Department, Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Centre de recherche du CHUM, Centre Hospitalier de l'Université de Montréal, Montréal, Canada.
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Chivapricha W, Srinonprasert V, Suansanae T. Impact of Geriatric Pharmacy Specialist Interventions to Reduce Potentially Inappropriate Medication Among Hospitalized Elderly Patients at Medical Wards: A Prospective Quasi-Experimental Study. Drugs Real World Outcomes 2020; 8:39-47. [PMID: 33063296 PMCID: PMC7984164 DOI: 10.1007/s40801-020-00214-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2020] [Indexed: 11/26/2022] Open
Abstract
Background Elderly patients are at greater risk of receiving potentially inappropriate medications (PIMs) and developing adverse drug events. Identification and correction of PIMs is essential to maximize medication safety. Objective To determine the prevalence of PIMs on admission in Thai elderly patients admitted to a medical ward and to compare changes of PIMs on discharge, following comprehensive care by a ward pharmacist with or without a geriatric pharmacy specialist. Patients and method A prospective, quasi-experimental study was performed at a tertiary university hospital in Bangkok, Thailand. Patients aged ≥ 60 years who were admitted to the medical ward were recruited and allocated to one of two groups: intervention (IG) and control (CG). The CG received pharmaceutical care from the ward pharmacist. The IG received pharmaceutical care from the geriatric pharmacy specialist along with the ward pharmacist. The 2012 Beers criteria were used to identify PIMs on admission, during hospitalization, and on discharge. Results Prevalence of PIMs on admission was 43.3% (N = 187). On discharge, prevalence of PIMs in the IG decreased significantly compared to that on admission (21.3% and 43.3%, p < 0.05) and was significantly lower than in the CG (21.3% and 40.9%, p = 0.036). Moreover, the percentage of patients without PIMs on discharge in the IG was significantly higher than in the CG (78.7% and 59.1%, p < 0.0001). Conclusion Use of PIMs was common among hospitalized elderly patients on admission. Pharmaceutical care provided by a geriatric pharmacy specialist in conjunction with a ward pharmacist significantly reduced the prevalence of PIMs on discharge compared with on admission.
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Affiliation(s)
| | - Varalak Srinonprasert
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanarat Suansanae
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand.
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Platts-Mills TF, Zimmerman S, Sloane PD. Increasing the Value of Emergency Visits for Long-term Care Patients: When Less is More and More is More. J Am Med Dir Assoc 2019; 20:927-928. [PMID: 31353042 DOI: 10.1016/j.jamda.2019.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 06/21/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Timothy F Platts-Mills
- Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research and Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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The efficacy of a medication review programme conducted in an emergency department. Int J Clin Pharm 2019; 41:757-766. [DOI: 10.1007/s11096-019-00836-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/30/2018] [Indexed: 10/26/2022]
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Shenvi CL, Platts-Mills TF. Managing the Elderly Emergency Department Patient. Ann Emerg Med 2019; 73:302-307. [DOI: 10.1016/j.annemergmed.2018.08.426] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Indexed: 01/06/2023]
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Preston L, Chambers D, Campbell F, Cantrell A, Turner J, Goyder E. What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06160] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BackgroundEmergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address.ObjectivesTo systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes.DesignA systematic mapping review.SettingEvidence from developed countries on interventions delivered in the ED.ParticipantsFrail and high-risk older people and general populations of older people (aged > 65 years).InterventionsInterventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED.Main outcome measuresPatient outcomes (direct and indirect) and health service outcomes.Data sourcesEvidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016.Review methodsA review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made.ResultsOf the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes.LimitationsThis review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review.ConclusionsA substantial body of evidence on interventions for frail and high-risk older people was identified and mapped.Future workFuture work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients.Study registrationThis study is registered as PROSPERO CRD42016043260.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Louise Preston
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Janette Turner
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Botts SR, Gee MT, Chang CC, Young I, Saito L, Lyman AE. Design and implementation of population-based specialty care programs. Am J Health Syst Pharm 2017; 74:1437-1445. [PMID: 28887345 DOI: 10.2146/ajhp161016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The development, implementation, and scaling of 3 population-based specialty care programs in a large integrated healthcare system are reviewed, and the role of clinical pharmacy services in ensuring safe, effective, and affordable care is highlighted. SUMMARY The Kaiser Permanente (KP) integrated healthcare delivery model allows for rapid development and expansion of innovative population management programs involving pharmacy services. Clinical pharmacists have assumed integral roles in improving the safety and effectiveness of high-complexity, high-cost care for specialty populations. These roles require an appropriate practice scope and are supported by an advanced electronic health record with disease registries and electronic surveillance tools for care-gap identification. The 3 specialty population programs described were implemented to address variation or unrecognized gaps in care for at-risk specialty populations. The Home Phototherapy Program has leveraged internal partnerships with clinical pharmacists to improve access to cost-effective nonpharmacologic interventions for psoriasis and other skin disorders. The Multiple Sclerosis Care Program has incorporated clinical pharmacists into neurology care in order to apply clinical guidelines in a systematic manner. The KP SureNet program has used clinical pharmacists and data analytics to identify opportunities to prevent drug-related adverse outcomes and ensure timely follow-up. CONCLUSION Specialty care programs improve quality, cost outcomes, and the patient experience by appropriating resources to provide systematic and targeted care to high-risk patients. KP leverages an integration of people, processes, and technology to develop and scale population-based specialty care.
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Affiliation(s)
- Sheila R Botts
- Clinical Pharmacy Research and Academic Affairs, Central Support Services, Kaiser Permanente Colorado, Aurora, CO
| | - Michael T Gee
- Regional Clinical Pharmacy Services, Pharmacy Operations, Kaiser Permanente Northern California, Oakland, CA.
| | | | - Iris Young
- Pharmacy Quality and Medication Safety, Pharmacy Operations, Kaiser Permanente Northern California, Oakland, CA
| | - Logan Saito
- Regional Clinical Pharmacy Services, Kaiser Permanente Southern California, Downey, CA
| | - Alfred E Lyman
- Regional Pharmacy Services, Pharmacy Administration, Kaiser Permanente Northwest, Portland, OR
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Clinical Pharmacists Are Essential to the Care of Patients in the Emergency Department. Ann Emerg Med 2016; 68:392-3. [DOI: 10.1016/j.annemergmed.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Indexed: 11/21/2022]
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