Faculty Bibliography

INTRODUCTION/BACKGROUND:Many seriously injured older adults are not transported to trauma centers (TCs), a phenomenon known as undertriage. System-level factors that contribute to undertriage are poorly understood. One important system-level factor is the regional supply of TCs. We hypothesized that regions with greater supply of TCs would have higher rates of transport to a TC for seriously injured older adults. METHODS:In this retrospective cross-sectional study using Medicare data from 2014 to 2015, we measured the proportion of seriously injured (injury severity score > 15) older adults (age ≥ 65 y) who were transported to a level I or level II TC within trauma service areas (TSAs), which consist of United States counties aggregated into contiguous geographic regions based on the most frequent hospital destinations for emergency conditions. Patients residing in rural regions were excluded. The primary outcome was transported to a level I or level II TC. The exposure was the supply of TCs within TSAs, grouped into terciles based on the number of TCs per capita. We performed a multivariable hierarchical logistic regression for the odds of TC transport with a random intercept for TSA and fixed effects for TC supply, patient demographics, and injury characteristics. RESULTS:Our study included 68,128 seriously injured older adults residing in 309 TSAs. The tercile of TSAs with the lowest supply of TCs had 1.13 TCs per 1,000,000 population, and 38.8% of seriously injured older adults were transported to a TC. In contrast, the tercile with the highest supply of TCs had 4.15 TCs per 1,000,000 population, and 68.5% were transported to a TC. On multivariable hierarchical logistic regression, TSAs with the highest supply of TCs had four times higher odds of transport to a TC compared to TSAs with the lowest supply of TCs (odds ratio 4.23; 95% confidence interval: 3.32-5.38; P < 0.001). CONCLUSIONS:Older adults with serious injuries are more likely to be transported to a TC in TSAs with greater supply of TCs. Ensuring an appropriate supply of TCs within TSA regions may help to reduce rates of undertriage for seriously injured older adults.

Alzheimer's disease is the neurodegenerative disorder responsible for approximately 60% to 70% of all cases of dementia and is expected to affect 152 million by 2050. Recently, anti-amyloid therapies have been developed and approved by the Food and Drug Administration as disease-modifying treatments given as infusions every 2 to 5 weeks for Alzheimer's disease. Although this is an important milestone in mitigating Alzheimer's disease progression, it is critical for emergency medicine clinicians to understand what anti-amyloid therapies are and how they work to recognize, treat, and mitigate their adverse effects. Anti-amyloid therapies may be underrecognized contributors to emergency department visits because they carry the risk of adverse effects, namely amyloid-related imaging abnormalities. Amyloid-related imaging abnormalities are observed as abnormalities on magnetic resonance imaging as computed tomography is not sensitive enough to detect the microvasculature abnormalities causing vasogenic edema (amyloid-related imaging abnormalities-E) microhemorrhages and hemosiderin deposits (amyloid-related imaging abnormalities-H). Patients presenting with amyloid-related imaging abnormalities may have nonspecific neurologic symptoms, including headache, lethargy, confusion, and seizures. Anti-amyloid therapies may increase risk of hemorrhagic conversion of ischemic stroke patients receiving thrombolytics and complicate the initiation of anticoagulation. Given the novelty of anti-amyloid therapies and limited real-world data pertaining to amyloid-related imaging abnormalities, it is important for emergency medicine clinicians to be aware of these agents.

INTRODUCTION/BACKGROUND:The Geriatric Emergency Care Applied Research Network 2.0-Advancing Dementia Care (GEAR 2.0-ADC) aims to advance research efforts to improve the emergency care of persons living with dementia (PLWDs). OBJECTIVE:To support this objective, GEAR 2.0-ADC convened a virtual consensus conference to prioritize emergency care research opportunities for PLWDs inclusive of perspectives of PLWDs to ensure identification of research gaps in response to their experiences and priorities. Inclusion of PLWDs as research partners is increasingly recognized as a best practice, however, approaches to facilitating consensus participation are lacking. METHODS:Best practices for supporting the engagement of PLWDs in a consensus conference, applied across its three phases (pre-conference, during the conference, and post-conference), include: establishing a learning environment focused on research priorities before the event, presenting information in ways that align with participants' learning preferences while accommodating cognitive impairments, and providing multiple opportunities and methods for gathering post-conference feedback from PLWDs. RESULTS:These strategies were identified by PLWDs and care partners (CPs) through semi-structured interviews, who were involved in the convening process, aimed at exploring ways to enhance facilitation techniques for participants. CONCLUSION/CONCLUSIONS:Additionally, these summarized insights aim to encourage the use of community-engaged approaches in discussions and consensus-building around research priorities in emergency care, particularly for PLWDs and their CPs.

OBJECTIVES/OBJECTIVE:Abdominal pain is the most common reason for visit (RFV) to the emergency department (ED) for adults, yet no standardized diagnostic pathway exists for abdominal pain. Optimal management is age-specific; symptoms, diagnoses, and prognoses differ between young and old adults. Availability and knowledge of the effectiveness of various imaging modalities have also changed over time. We compared diagnostic imaging rates for younger versus older adults to identify practice patterns of abdominal imaging across age groups over time. METHODS:We analyzed weighted, nationally representative data from the National Hospital Ambulatory Medical Care Survey 2007-2019 for adult ED visits with a primary RFV of abdominal pain. We included 23,364 sampled visits, representing 123 million visits. RESULTS:From 2007 to 2019, total visits increased for ages 18-45 (p < 0.001), 46-64 (p < 0.001), and 65+ (p = 0.032). The percentage of visits with primary RFV of abdominal pain increased from 9.4% to 11.6% for ages 18-45, 7.8%-9.0% for ages 46-64, and 6.0%-6.5% for 65+. Computed tomography (CT) scan rates increased over time from 26.2% of all patients receiving a CT scan to 42.6%. Relative percentage change in abdominal CT scans was greatest for older adults, with a 30.3% increase, compared to 24.0% for middle-aged adults and 15.0% for young adults. Test positivity, defined as receiving an emergency general surgical diagnosis after CT or ultrasound, increased from 17.2% in 2007 to 22.9% in 2019 (p < 0.01). Of the older adults with abdominal pain in 2019, 13% received an X-ray only, which is neither sensitive nor specific for acute pathology in older adults. CONCLUSIONS:Despite more abdominal pain ED visits and increased imaging rates per visit, test positivity continues to rise. Our findings do not support claims that CT and ultrasound are being used less appropriately over time, but demonstrate widespread use of X-rays, which are potentially ineffective for abdominal pain.

BACKGROUND:Emergency department (ED) visits at end-of-life may cause financial strain and serve as a marker of inadequate access to community services and health care. We sought to examine end-of-life ED use, total healthcare spending, and out-of-pocket spending in a nationally representative sample. METHODS:Using Medicare Current Beneficiary Survey data, we conducted a pooled cross-sectional analysis of Medicare beneficiaries aged 65+ years with a date of death between July 1, 2015 and December 31, 2021. Our primary outcomes were ED visits, total healthcare spending, and out-of-pocket spending in the 7, 30, 90, and 180 days preceding death. We estimated a series of zero-inflated negative binomial models identifying patient characteristics associated with the primary outcomes. RESULTS:Among 3812 older adult decedents, 610 (16%), 1207 (31.7%), 1582 (41.5%), and 1787 (46.9%) Medicare beneficiaries had ED visits in the final 7, 30, 90, and 180 days, respectively, of life. For Medicare beneficiaries with at least one ED visit in the final 30 days of life, the median total and out-of-pocket costs were, respectively, $12,500 and $308, compared, respectively, with $278 and $94 for those without any ED visits (p < 0.001 for both comparisons). Having a diagnosis of dementia (odds ratio [OR] 0.71; 95% confidence interval [CI] 0.51-0.99; p = 0.04) and being on hospice status during the year of death (OR 0.56; 95% CI 0.48-0.66; p = <0.001) were associated with a decreased likelihood of having an ED visit. Having dementia was associated with a decreased likelihood of having any healthcare spending (OR 0.50; 95% CI 0.36-0.71; p = 0.001) and any out-of-pocket spending (OR 0.51; 95% CI 0.36-0.72; p = <0.001). CONCLUSIONS:One in three older adults visit the ED in the last month of life, and approximately one in two utilize ED services in the last half-year of life, with evidence of associated considerable total and out-of-pocket spending.

OBJECTIVES/OBJECTIVE:Older adults may present to the emergency department (ED) with agitation, a symptom often resulting in chemical sedation and physical restraint use which carry significant risks and side effects for the geriatric population. To date, limited literature describes the patterns of differential restraint use in this population. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS/METHODS:This retrospective cross-sectional study used electronic health records data from ED visits by older adults (age ≥65 years) ranging 2015-2022 across nine hospital sites in a regional hospital network. Logistic regression models were estimated to determine the association between patient-level characteristics and the primary outcomes of chemical sedation and physical restraint. RESULTS:Among 872,587 ED visits during the study period, 11,875 (1.4%) and 32,658 (3.7%) encounters involved the use of chemical sedation and physical restraints respectively. The populations aged 75-84, 85-94, 95+ years had increasingly higher odds of chemical sedation [adjusted odds ratios (AORs) 1.35 (95% CI 1.29-1.42); 1.82 (1.73-1.91); 2.35 (2.15-2.57) respectively] as well as physical restraint compared to the 65-74 group [AOR 1.31 (1.27-1.34); 1.55 (1.50-1.60); 1.69 (1.59-1.79)]. Compared to the White Non-Hispanic group, the Black Non-Hispanic and Hispanic/Latinx groups had significantly higher odds of chemical sedation [AOR 1.26 (1.18-1.35); AOR 1.22 (1.15-1.29)] and physical restraint [AOR 1.12 (95% CI 1.07-1.16); 1.22 (1.18-1.26)]. CONCLUSION/CONCLUSIONS:Approximately one in 20 ED visits among older adults resulted in chemical sedation or physical restraint use. Minoritized group status was associated with increasing use of chemical sedation and physical restraint, particularly among the oldest old. These results may indicate the need for further research in agitation management for historically marginalized populations in older adults.

BACKGROUND/UNASSIGNED:Older adults treated in emergency departments (EDs) are at higher risk for adverse outcomes. Using multiple facilities can worsen this issue through service duplication and poor care transitions. Veterans with dual insurance coverage can access both Veterans Health Administration (VHA) and non-VHA EDs. This study aimed to identify factors associated with non-VHA ED use among veterans. METHODS/UNASSIGNED:We conducted a retrospective observational study of patients aged ≥ 65 who had primary care at the James J Peters VA Medical Center and at least one VHA or non-VHA ED visit between October 2017 and February 2020. Data were collected from the Veterans Affairs Corporate Data Warehouse and the Bronx Regional Health Information Exchange Organization. Generalized linear mixed models were used to examine factors influencing non-VHA ED use. RESULTS/UNASSIGNED:The study sample consisted of 3,897 veterans and a total of 13,312 ED visits. Compared to VHA-exclusive ED users, non-VHA ED users were more likely to live farther away (OR 1.04, CI 1.02 - 1.06) and seek care outside regular hours, including mornings (OR 1.61, CI 1.39 - 1.87), nights (OR 1.49, CI 1.33 - 1.66), weekends (OR 1.28, CI 1.16 - 1.42), and holidays (OR 1.32, CI 1.04 - 1.68). They were also more likely to present with emergency care sensitive conditions (OR 2.13, CI 1.90 - 2.37) and recent inpatient hospitalizations (OR 1.22, CI 1.05 - 1.41). CONCLUSION/UNASSIGNED:These findings suggested that distance and acuity are important predictors of non-VHA ED use in urban areas such as the Bronx, NY. Identifying veterans with key risk factors could improve care coordination and potentially reduce non-VHA ED use.

As the population ages, the prevalence of cognitive impairment due to neurodegenerative diseases such as Alzheimer disease (AD) is expected to double in the United States to nearly 14 million over the next 40 years. AD and related dementias (ADRD) are a leading cause of morbidity and mortality and among the costliest to society. Although emerging biomedical interventions for ADRD focus on early stages and are currently limited to AD, care management can benefit patients with ADRD across the disease course. Moreover, some causes of cognitive impairment are modifiable, and optimal overall management may slow or prevent additional decline. Nevertheless, a sizable proportion of cases of cognitive impairment among older adults remain undiagnosed. Primary care practitioners are often the first health care professionals to encounter cognitive concerns or to be able to observe changes in function resulting from cognitive impairment; hence, they have much to contribute to population health solutions for detecting cognitive impairment among older adults. In this report, we present key points and gaps in knowledge about methods for detecting cognitive impairment in primary care clinics. These were developed via an interdisciplinary Geriatrics Summit hosted by the National Academy of Neuropsychology in 2022, attended by representatives of national organizations engaged in work to improve care of older adults. We propose a novel workflow to facilitate detecting cognitive impairment during routine primary care, focusing on opportunities provided by the annual wellness visit, a preventive visit available to Medicare beneficiaries, along with additional recommendations and opportunities for clinical practice and research.