A Qualitative Study of "What Matters" to Older Adults in the Emergency Department

Cameron J. Gettel, MD, MHS; Arjun K. Venkatesh, MD, MBA, MHS; Hollie Dowd, BA; Ula Hwang, MD, MPH; Rockman F. Ferrigno, MD; Eleanor A. Reid, MD, MSc; Mary E. Tinetti, MD

Disclosures

Western J Emerg Med. 2022;23(4):579-588. 

In This Article

Abstract and Introduction

Abstract

Introduction: The "4Ms" model – What Matters, Medication, Mentation, and Mobility – is increasingly gaining attention in age-friendly health systems, yet a feasible approach to identifying what matters to older adults in the emergency department (ED) is lacking. Adapting the "What Matters" questions to the ED setting, we sought to describe the concerns and desired outcomes of both older adult patients seeking ED care and their treating clinicians.

Methods: We conducted 46 dyadic semi-structured interviews of cognitively intact older adults and their treating clinicians. We used the "What Matters" conversation guide to explore patients' 1) concerns and 2) desired outcomes. We then asked analogous questions to each patient's treating clinician regarding the patient's priorities. Interviews were professionally transcribed and coded using an inductive approach of thematic analysis to identify emergent themes.

Results: Interviews with older adults lasted a mean of three minutes, with a range of 1–8 minutes. Regarding patients' concerns, five themes emerged from older adults: 1) concern through a family member or outpatient clinician recommendation; 2) no concern, with a high degree of trust in the healthcare system; 3) concerns regarding symptom cause identification; 4) concerns regarding symptom resolution; and 5) concerns regarding preservation of their current status. Regarding desired outcomes, five priority themes emerged among older adults: 1) obtaining a diagnosis; 2) returning to their home environment; 3) reducing or resolving symptoms; 4) maintaining self-care and independence; and 5) gaining reassurance. Responding to what they believed mattered most to older adult patients, ED clinicians believed that older adults were concerned primarily about symptom cause identification and resolution and primarily desired a return to the home environment and symptom reduction.

Conclusion: This work identifies concerns and desired outcomes of both older adult patients seeking ED care and their treating clinicians as well as the feasibility of incorporating the "What Matters" questions within ED clinical practice.

Introduction

Older adults (those aged 65 years and over) account for over 23 million emergency department (ED) visits annually, representing 18% of all ED visits nationally.[1] Older adults have been noted to face unique challenges related to emergency care, including the potential receipt of goal-discordant care and a decreased attention to patient-centered care.[2,3] As a potential solution to address the underlying problems facing older adults more broadly in healthcare settings, the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) founded the Age-Friendly Health Systems initiative in 2017.[4–7] As of June 2021,[4] there were over 2200 age-friendly health system participants employing the framework called the "4Ms" – What Matters, Medication, Mentation, and Mobility – to ensure patient-centered and evidence-based care for older adults across healthcare settings, with wider implementation in ambulatory and inpatient settings and less attention to the ED setting.[8–10]

Within EDs, efforts are increasing to prioritize patient-centeredness and goal-concordant care for older adults.[11,12] These areas of focus are particularly relevant and important for older adults as they have been identified in the outpatient setting to have health-related priorities aside from typical metrics such as repeat ED visits or hospitalization.[13–15] Furthermore, much of the available emergency care research regarding older adults' patient-centered goals currently focuses on treating clinicians performing end-of-life goals of care conversations.[16–18] However, ED treating clinicians are tasked with navigating older adult priorities not just during critical illness or end of life.

To date, the extant literature has not assessed whether ED treating clinicians perceive priorities that differ from their older adult patients, thereby potentially introducing goal-discordant care. Identifying what matters and priorities within the broader older adult population has drawn concerns regarding implementation strategies in the ED clinical environment as the lines of questioning often are perceived as time-intensive[19] or beyond the scope of a traditional ED visit focused on a single injury or symptom. Thus far, a feasible approach aligned with the Age-Friendly Health Systems to identify what matters to older adults seeking emergency care is lacking. Therefore, we sought to describe the priorities identified by older adults' and their treating clinicians as well as the feasibility of incorporating brief questions addressing what matters in the ED. Identifying the concerns and desired outcomes of older adults in a time-efficient approach that is aligned with the "What Matters" domain of the 4Ms framework will allow more patient-centered ED care for this growing population.

processing....