Over 70% of elderly patients are not questioned on their ability to care for themselves prior to discharge; 20% disclose that they do not understand their discharge instructions.This subset of the older adult population may have difficulty comprehending and following their discharge instructions. This may lead some patients to return when their initial complaints do not improve due to uncertainty and lack of comprehension regarding their discharge diagnoses, treatment, and follow-up plans.Several studies indicate poor cognitive health also is an important driver of ED returns. Older-adult patients with cognitive and memory impairment were at an increased risk for 30-day returns, and several studies demonstrated it to be anindependent predictor for these returns.However, Ostir et al. found that poor cognitive health and odds of 30-day revisits did not have a significant association.Although, Ostir et al. did find that higher cognitive health scores were linked to lower risk for unplanned ED revisits at 60- and 90-days post-index visit.The authors found that every one-point increase in cognitive score was associated with 24% and 21% decreased odds of 60-day and 90- day revisits to the ED, respectively. The lack of significant association between poor cognitive health and increased 30-day returns by Ostir et al. may be explained by several differences in the study population, which was mostly female , African American , and with cognitive impairment . The average cognitive score of these patients was 4.5 points below standardized norms for persons 65 years and older,whereas 76.8% of the study population in the McCusker et al. study had no impairment or only mild cognitive impairment.Only 18.7% of patients in the de Gelder et al. study were found to have cognitive impairement.Since nearly all patients in the Ostir et al. study had cognitive impairment, their findings may be due to the lack of an adequate comparison group.
There are several possible explanations why patients with poor cognitive health may be at increased risk for recidivism,industrial rolling racks including suffering from more complex comorbidities necessitating more frequent healthcare, decreased comprehension of ED discharge diagnoses and instructions, and decreased accuracy in reporting of presenting illness. Patients with delirium superimposed on dementia were found to have lower concordance with their surrogates regarding reason for ED presentation reported to ED staff.This discordance between presenting complaints may lead to insufficient evaluation, missed diagnosis, and/or inappropriate discharge, particularly when the surrogate is not available during the ED evaluation. In addition to cognitive health, poor physical function and poor general health also increase odds of returning within 30 days, and may be an independent predictor for ED recidivism.As physical functioning is a well-established predictor of outcomes among elderly patients, these findings likely reflect the characteristics of a sicker aging population. Several studies have shown that patients, despite access to care , prefer to seek care in the ED compared to the outpatient setting.Reasons include the following: accessibility/convenience; perceived urgency of complaints; inability to wait for scheduled primary care follow-up due to worsening of persistence of symptoms; expedited diagnostic testing; perceived availability of specialists; lack of transportation to primary care office; and wanting a second opinion, among other reasons. In a study of the general ED population, uninsured patients were not found to use the ED more than insured patients, but they use other types of care less. Interestingly, both the insured and uninsured visit the ED at similarly high rates for non-emergent complaints or complaints that can be treated in non-ED settings.
As discussed previously, patient fear or uncertainty likely plays an important role in understanding why patients come to the ED. This sense of uncertainty regarding the cause of their symptoms is best illustrated by Castillo et al.’s findings of a rather high rate of older adults returning to the ED for the same primary diagnosis and many seeking care at a different facility , perhaps in hopes of finding a different conclusion from their index ED visit.In a qualitative study of 40 adult patients with chronic cardiovascular disease or diabetes, patient reported driving factors for ED returns included feeling a sense of fear or uncertainty with negative test results and expecting a diagnosis for their symptoms. Many patients who did not receive a clear diagnosis for their symptoms reported needing to return until a diagnosis was found.In two studies of older adults, patients were less likely to consider that their complaint has been completely resolved and believed they would be less independent after discharge from the ED.A survey of 15 older adults also linked patient perception of ED care with ED recidivism, including believing that the ED was their “only option” and that their symptoms required specialized care only provided in the ED.Several patients also reported that they believed their primary care physician would have advised them to seek care in the ED for their symptoms. Others reported receiving ineffective treatments or instructions at the time of ED discharge. In some cases, this perception may stem from inadequate patient counseling regarding expectations and reasonable goals of care and that can be achieved during the ED visit.The older adult population is a key and significant contributor to ED recidivism and is responsible for a disproportionate amount of healthcare costs. For this reason, older adults have received much attention and study to create interventions aimed at reducing ED recidivism.
The unique characteristics of this patient group should be considered when developing strategies to minimize ED returns. The generation of a profile for elderly patients at increased risk for ED returns could identify potential targets for individualized education, counseling, and other interventions to reduce ED over-utilization. Many of the study results discussed in this review were performed outside the U.S. and thus may not be fully generalizable to older adults residing in the U.S. due to different social and cultural influences and healthcare systems. However, when data was available for comparison, studies performed in the U.S. identified many similar risk factors for return visits in older adults as the non-U.S. studies. These similarities suggest that the underlying reasons for ED utilization by older adults may be influenced more by themes related to aging rather than the cultures or healthcare models of individual countries. However, it is important to note that these studies were all performed in highly developed countries with stable economies and well established healthcare systems. Therefore, whether the identified risk factors would remain true in developing countries with fewer healthcare resources is unknown and deserves further study. Further study is needed to understand how each of these areas influences return visits, how they influence each other, and to resolve discrepancies in previously reported findings.Academic medicine faces a challenge on how to balance the objectives of revenue production with compensation of scholarly achievement. Historically, “relative value units” have been used to incentivize physicians to improve clinical productivity, but these systems have neglected to recognize non-clinical achievements, such as those related to teaching, academic leadership roles, or other scholarly activity. Many non-clinical activities do not earn a reduction in clinical hours or financial incentive, which may result in decreased motivation to contribute academically as well as frustration and burnout. As faculty members work to advance in their professional careers,4×4 grow table diminished scholarly output may create a barrier for promotion possibilities at traditional academic institutions. All of this may result in less time devoted to teaching and diminished opportunities for mentorship and role modeling for learners. To foster academic productivity and the retention of talented physicians, academic medicine must recognize and reward the effort that is necessary to thrive within it.1 Models have been introduced over the past decade that focus on incentivizing non-clinical activities. Some of these models have focused solely on education and teaching commitments using a teaching or educational value unit system to weigh activities.Others have cast a broader net encompassing all academic activities, including education, teaching, committee and administrative roles, and research, using a clinical or academic relative value unit model.Problems were identified in our department with regards to education and scholarly activity. The residency group and a small group of core faculty have traditionally carried much of the teaching effort, resulting in an unequal distribution of educational commitments across the department. In addition to education, many in the department participate in other scholarly work such as research projects earning grant funding, peer previewed publications, lecturing engagements, and leadership or committee positions. Similar to other academic institutions, our department has experienced difficulty tracking faculty activities outside of clinical work.
Faculty frustration has resulted from many of these activities not being compensated financially or rewarded with reduced clinical hours. Furthermore, junior faculty lacked an understanding of the importance of tracking academic activities as a way to monitor their progress and to focus on areas that required more attention in preparation for the promotion process. We brainstormed ideas regarding how to expand faculty commitment to better align with our academic mission, to prepare faculty for promotion, and to create an improved infrastructure fostering resident and student mentoring. Our project had several objectives: 1) realign and redistribute the responsibility for meeting education needs equitably across the department; 2) create a system of accountability and transparency based on faculty consensus; 3) recognize and reward academic activities that go above minimum expectations; 4) align faculty academic productivity with institutional promotion procedures; 5) build a system that houses academic activities in a format consistent with institutional teaching portfolio expectations; 6) incentivize and increase departmental scholarly output; and 7) build a system capable of supporting an academic mentoring infrastructure for our learners. In 2017 we initiated a two-stage project to redesign education expectations and to identify and recognize the full spectrum of academic activities among all faculty. Stage one involved the creation of a mandatory baseline educational participation process; stage two, implemented later, involved the creation of an ARVU points system with identified voluntary academic participation. Both stages of the project were tied to an academic financial incentive awarded at year-end. Our goal was to determine the effects of this project on faculty baseline participation in educational activities as well as monitor academic productivity and advancement within the department.Stage one, initiated in July 2017, created minimum education expectations and accountability procedures, incorporating two related requirements. The first included attending a minimum number of resident conferences per year, inversely proportional to a faculty member’s clinical load. The second element required participation in a module system, created by the residency, where each month represented one module and focused on a particular topic. Each faculty member was required to sign up for and commit to specific dates during a module where they were responsible for taking part in teaching activities assigned by the residency or undergraduate medical education group. These activities included such things as giving a lecture, moderating a journal club, running a small group session, or teaching a procedural skills lab among others. The sign-up process afforded some flexibility and choice, as faculty could pick dates that worked for them and topics they were most interested in. Conference attendance required only the presence of faculty in the audience, but module participation required the active participation of faculty in specified activities. Conference attendance and module participation were chosen as minimum expectations for two reasons: firstly, all faculty historically have been expected to participate in residency and student teaching as part of their academic appointment to the medical school; and secondly, these activities were considered to require the heaviest lift and were inequitably distributed among the faculty. These new expectations were required of faculty across the department and were tied to a newly created academic incentive awarded at fiscal year-end. The faculty who did not meet these new education expectations were not eligible for this financial incentive. After soliciting feedback on these new expectations through faculty meeting discussions and offline conversations, most agreed that the new expectations were not overly burdensome. However, two main concerns surfaced. One was that the academic incentive was not reflective of other non-clinical activities valuable to the department’s mission. A second concern brought forth by the residency leadership was that the expectations did not include resident assessments, which historically had a low response rate. Based on this feedback, the baseline education expectations were revised to include completion of a percentage of resident post-shift assessments over the academic year, inversely proportional to a faculty member’s clinical load.