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Discharging older patients from the emergency


department effectively: a systematic review and
meta-analysis
ARTICLE in AGE AND AGEING AUGUST 2015
Impact Factor: 3.64 DOI: 10.1093/ageing/afv102 Source: PubMed

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Judy Lowthian

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Monash University (Australia)

Monash University (Australia)

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Monash University (Australia)
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Available from: Judy Lowthian


Retrieved on: 21 October 2015

Age and Ageing Advance Access published August 10, 2015


Age and Ageing 2015; 0: 110
doi: 10.1093/ageing/afv102

The Author 2015. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: journals.permissions@oup.com

SYSTEMATIC REVIEW

Discharging older patients from the emergency


department effectively: a systematic review
and meta-analysis
JUDY A. LOWTHIAN, ROSEMARY A. MCGINNES, CAROLINE A. BRAND, ANNA L. BARKER, PETER A. CAMERON
Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University,
Melbourne, Victoria, Australia
Address correspondence to: J. A. Lowthian. Tel: (+61) 399030360. Email: judy.lowthian@monash.edu

Abstract
Background: a decline in health state and re-attendance are common in people aged 65 years following emergency department (ED) discharge. Diverse care models have been implemented to support safe community transition. This review examined ED community transition strategies (ED-CTS) and evaluated their effectiveness.
Methods: a systematic review and meta-analysis using multiple databases up to December 2013 was conducted. We assessed eligibility, methodological quality, risk of bias and extracted published data and then conducted random effects meta-analyses.
Outcomes were unplanned ED representation or hospitalisation, functional decline, nursing-care home admission and mortality.
Results: five experimental and four observational studies were identied for qualitative synthesis. ED-CTS included geriatric assessment with referral for post-discharge community-based assistance, with differences apparent in components and delivery
methods. Four studies were included in meta-analysis. Compared with usual care, the evidence indicates no appreciable benet
for ED-CTS for unplanned ED re-attendance up to 30 days (odds ratio (OR) 1.32, 95% condence interval (CI) 0.991.76;
n = 1,389), unplanned hospital admission up to 30 days (OR 0.90, 95% CI 0.701.16; n = 1,389) or mortality up to 18 months
(OR 1.04, 95% CI 0.831.29; n = 1,794). Variability between studies precluded analysis of the impact of ED-CTS on functional
decline and nursing-care home admission.
Conclusions: there is limited high-quality data to guide condent recommendations about optimal ED community transition
strategies, highlighting a need to encourage better integration of researchers and clinicians in the design and evaluation process,
and increased reporting, including appropriate robust evaluation of efcacy and effectiveness of these innovative models of care.
Keywords: emergency, discharge, meta-analysis, older people

Demographic change poses a distinct challenge for Emergency


Departments (EDs), with attendances by older people aged
65 years accelerating at a rate beyond that due to population
ageing [1, 2]. This age group constitutes 18% of attendances
across Australia, UK, USA and Canada [3]. Older people presenting to ED often have complex medical and psychosocial
issues that lead to longer lengths of stay, increased likelihood
of admission [2] and require more resources to fully understand presenting complaints [3]. The hazards of hospitalisation [4] add to pressures faced by clinicians in the context of
time-based targets, ED ow, resource allocation and requisite
need to uphold quality and safety of care.

An ED attendance is described as a sentinel event for


an older person [5, 6], with associated functional decline and
other adverse outcomes including subsequent increased risk
of re-presentation well documented [79]. With 45% of older
patients discharged directly home from ED [10], diverse
models of care have been employed across Canada [11], USA
[12, 13], UK [1416], Europe [17, 18] and Australia [19] to
support safe transition. Comprehensive guidelines have been
published in the UK [20] and USA [21]; however, these focus
on the ED stay. There is no consensus within similar systems
of care, as to what constitutes evidence-based best practice for
patients discharged home from ED.

J. A. Lowthian et al.
Previous reviews have examined effects of different types
of ED-based care models [2224]; however, their impact on
outcomes has not been quantied. We therefore conducted a
systematic review with meta-analysis to (i) prole effective
care transition models and (ii) provide robust estimates of
effect of these care models on risk of ED re-presentation or
hospitalisation, functional decline in activities of daily living
(ADL), nursing-care home admission and mortality in older
people discharged home from ED. This study is part of the
Safe Elderly Emergency Discharge (SEED) project [25]
aimed to develop a best practice model of care for older
patients discharged from ED.

Methods
A systematic review and meta-analysis was conducted and
reported in accordance with the PRISMA Statement [26].
Study design was informed by the Cochrane Effective
Practice and Organisation of Care approach for appraising
clinical trials [27], specically elements pertaining to identication and screening of sources, quality assessment and data
extraction. The protocol is available on our project website
(www.seed.monash.org.au).
Data sources and search strategy

An electronic search was conducted on OVID Medline


(1946 to December 2013) and Cochrane Library (2005 to
December 2013) databases. A library scientist guided development of the search strategy. Medical subject heading search
terms and text or keywords associated with concepts of geriatric or older adults; emergency; evaluation, assessment or intervention; discharge or follow-up were used as detailed in
Supplementary data, Appendix S1, available in Age and Ageing
online. No language or publication time lines were applied.
The search strategy was translated for the CINAHL database
(1937 to December 2013). Bibliographies of included articles
were examined for additional references.
Study selection

Two reviewers (R.M., J.C.) independently assessed eligibility


of retrieved articles by screening titles and abstracts. Queries
were resolved through discussion with J.L.
Inclusion criteria

Articles that described effectiveness of discharge and care


transition strategies formulated in the ED, for patients aged
65 years who were discharged home, were included. We considered randomised and quasi-randomised trials, controlled
before/after trials and controlled interrupted time series. We
took a pragmatic approach and also considered observational
studies including comparative controlled cohort, case control
and before/after studies, because health services research is
necessarily restricted by practical and ethical barriers when
introducing new practice to improve quality of care [28],

including that conducted in EDs. Studies were included if


there was comparison of the intervention with a historical
or contemporaneous control group, with data reported on
post-discharge outcomes typically used as a measure of effectiveness of ED care transition. These included unplanned ED
re-presentation, emergency hospitalisation, functional decline
in ADL including nursing home admission and death.
Exclusion criteria

Studies that included patients admitted to hospital, described


single disease management models (e.g. fracture, falls, delirium) or failed to report adequate information about postdischarge outcomes were excluded.
Data extraction and quality assessment

Data extraction was conducted independently ( J.L., R.M.) and


cross-checked for accuracy using a tool based on the National
Health and Medical Research Council guidelines [29] used previously [30]. Study setting and design, selection and measurement bias, baseline and follow-up outcome measurements,
risk of bias, intervention characteristics, summary measures including odds and risk ratios and percentage mean differences,
intention-to-treat analysis, study power and issues pertaining
to generalisability were extracted.
Risk of bias for RCTs was rated independently ( J.L., R.M.)
according to the Cochrane Collaborations tool [31] and a
high/moderate/low score was generated [32]. Observational
study quality was evaluated using the Newcastle-Ottawa Scale
(NOS) [33]; however, the inherent high level of bias and potential over-estimation of intervention effectiveness in such
designs were taken into consideration. The maximum possible
score was 8 points, with study quality categorised as high
(68), moderate (4 or 5) or low (03) [32].
Data synthesis and analysis

Data regarding characteristics and effectiveness of ED community transition strategy (ED-CTS) in comparison with usual
care were extracted. Sample size estimations were reported,
based on predetermined primary outcomes of an expected
510% reduction in unplanned ED re-presentation or hospital
admission. If studies were under-powered for a given outcome,
results are presented when they met requirements for clinical
and statistical heterogeneity. All data were synthesised and
analysed to describe the impact of ED-CTS on different
outcomes.
Our primary meta-analyses were of RCTs with low risk of
bias. We then added the high-quality observational studies as
secondary analyses, in an attempt to see whether they altered
the estimate of the intervention effect [34, 56]. Meta-analyses
were performed using RevMan V5.2 software (Cochrane
Collaboration, Oxford, UK) employing random effects models
that provide more conservative estimates of treatment effect
in the presence of heterogeneity [35]. Heterogeneity was quantied using the I 2 statistic, the percentage of variation across

Decline in health state and re-attendance in older people following ED discharge


studies due to between-study heterogeneity rather than chance.
We deemed it not appropriate to report on pooled results with
moderate to large heterogeneity across studies (I 2 > 50%) [36].
Given the small number of studies included in the metaanalysis, meta-regression was not possible.

Results
Selected studies

Search results are summarised in Figure 1. Eleven papers describing nine studies met our selection criteria for inclusion
in qualitative synthesis. These studies, published between
1996 and 2013, included four randomised controlled trials
(RCTs), one quasi-RCT, three uncontrolled before/after
studies and one comparative controlled study. Studies were
conducted from 1991/92 to 2009/10 in Australia [37, 38],
Canada [3942], USA [43, 44], Scotland [45], Hong Kong
[46] and Singapore [47].
Table 1 outlines key characteristics and summary outcome
results. There were differences in recruited patient populations
with some criteria being age-related [37, 40, 43, 45, 47] and
others based on high risk of poor outcomes [38, 41, 44, 46].
All patients or their primary care givers in these studies provided informed consent, enabling inclusion of patients
without capacity. There were also differences in the components and delivery methods of care models as summarised in
Supplementary data, Appendix Table S3, available in Age and
Ageing online. All CTS included geriatric assessment but with
differing delivery by nurses, allied health professionals or
trained health visitors. Post-discharge interventions focussed
on community-based referral, with some providing telephone follow-up, GP liaison [45] and/or direct linkage and/
or short-term outreach assistance until community-based
services became available [37, 4345]. Follow-up periods
were variable, ranging from 14 days to 18 months. Finally,
there was heterogeneity in reported outcomes, with unplanned ED re-presentation or emergency hospital admission measured in all studies and institutionalisation in three
studies [37, 43, 46]. All studies measured a combination of
healthcare and patient clinical outcomes, with six studies
measuring functional decline [37, 42, 45, 46] or mortality
[37, 43, 47].

Methodological quality and risk of bias

Methodological domains used to generate risk of bias grading


of RCTs and the quasi-RCT [31] (sequence generation and/or
loss to follow-up) and quality rating of observational studies
[33] (total number of Newcastle-Ottawa Scale is described in
Supplementary data, Appendix Table S2, available in Age and
Ageing online. Two RCTs were evaluated as having low risk of
bias [37, 43]. Both RCTs predetermined their sample size on
dened primary outcome measures. Observational study
quality varied, with two judged to be of high quality (Guttman
before/after trial [40] and Arendts casecontrol study [38]).

ED-CTS effectiveness

Four studies had sufcient clinical and methodological


homogeneity (cohorts, follow-up periods, strategies and
outcome measurement) to allow comparison for inclusion in
meta-analysis [37, 38, 40, 43].
Outcomes

Meta-analysis was conducted for outcomes of unplanned


ED re-attendance, emergency hospitalisation and mortality
at specic follow-up points as summarised in Figure 2.
Unplanned ED re-presentation

Pooled data showed no effectiveness at reducing our primary


outcome of unplanned ED re-attendance up to 1 month in
the RCTs (odds ratio (OR) 1.32, 95% condence interval
(CI) 0.991.76; n = 1,389) (Figure 2i). Moderately high heterogeneity (I 2 = 69%) was apparent when the observational
studies were included in meta-analysis (Figure 2i).
While individual RCTs demonstrated no signicant differences in outcomes, the Arendts observational study noted
an increase in re-presentation rate at 28 days by patients
determined to be at high risk (17.9 versus 14.8%, P = 0.05);
while Guttman reported signicant reduction in early ED
return at 14 days (relative risk (RR) = 0.79, 95% CI 0.50.96)
(Table 1).
Emergency hospital admission

Meta-analysis showed no inuence on hospitalisation at 1


month after initial attendance (OR 0.89, 95% CI 0.651.21;
n = 1,389), with similar results when the before/after trial
was included (OR 0.90, 95% CI 0.701.16; n = 3,113)
(Figure 2ii).
Functional decline in ADL

Functional decline in ADL was only measured in the Caplan


and Mion RCTs, at different time points (6 and 12 months
[37]; 1 and 4 months [43], respectively). Caplan compared
changes in functional status as a secondary outcome, reporting a greater degree of independence in ADL at 6 months
and no decline in cognitive function at 12 months in the
ED-CTS group. However at 18 months, deterioration in
ADL and cognitive status was reported for both groups.
Mion reported no impact on physical or mental function
with the intervention at either time point. Results could not
be pooled because of the diversity of measures and methods
of outcome reporting.
Nursing-care home admission

Nursing-care home admission, a marker of functional decline,


was a primary outcome in the Mion trial, with ED-CTS
patients signicantly less likely to be institutionalised at 30 days
(OR 0.21, 95% CI 0.050.99). The proportion of intervention

J. A. Lowthian et al.

Figure 1. Search results (PRISMA [26]).

patients transferred to permanent care remained lower at 4


months; however, this was not statistically signicant. Subgroup
analysis of high-risk patients revealed a signicant reduction in
institutionalisation at 30 days and 4 months, albeit with wide
condence intervals (2 versus 7%: OR 0.2, 95% CI 0.040.96;
and 3 versus 10%: OR 0.3, 95% CI 0.070.94, respectively).

Caplan reported no difference in care home admission at 18


months. Pooling these results indicated moderately high heterogeneity (I 2 = 67%).
No signicant effect on mortality was detected as a secondary outcome at any time point measured when the Caplan,
Mion and Arendts results were pooled (Figure 2iii). Death

Decline in health state and re-attendance in older people following ED discharge


Table 1. Summary of included studies investigating effectiveness of ED community care transition strategies for older patients
aged 65 years
Study

Setting
population

Study design,
length and year

Intervention elements

Outcomes

Results: % difference or
odds ratio (95% CI)

....................................................................................
Randomised studies
Caplan
1 Australian ED RCT
et al. [37]
75 years
18 months
1996/97

Runciman
et al. [45]

Mion
et al. [45]

1 Scottish ED
75 years

2 US EDs
65 years

RCT
4 weeks
1991/92

RCT
4 months
1999/00

4 Canadian EDs Quasi-RCT


McCusker
4 months
65 years
et al. [39, 41,
1998/99
High-risk
42]
patients

Yim
et al. [46]

3 Hong Kong
EDs
65 years
High-risk
patients

RCT
6 months
2008/09

739

424

650

345

1,279

Comprehensive geriatric nurse


Assessment
+ home visit within 24 h
+ formulation of discharge care plan
+ referrals
+ GP liaison
+ 4-week home-based intervention
+ weekly interdisciplinary team
meetings
+ seamless transfer of care to
community-based services

Primary
30-day hospital
admissions (any)
Secondary
30-day emergency hospital
admission
30-day ED re-presentation
18-month emergency
hospital admission
18-month nursing home
admission
18-month death
Other
6-month physical
functional decline
(Barthel, IADL)
12-month cognitive
functional decline
(MSQ)
Health visitor home visit and assessment 4-week re-admission
4-week dependency and
within 24 h of ED discharge with
functional ADL (Katz)
development of community services
4-week dependency and
package
functional IADL
+ discussion with patient and GP
(Fillenbaum)
+ service provision arrangement
Comprehensive geriatric nurse assessment Primary
+ formulation of discharge care plan
30-day ED re-presentation
+ referrals
30-day hospitalisation
+ GP liaison
30-day nursing home
+ telephone follow-up until
admission
Secondary
community-based services transfer
30-day death
120-day ED
re-presentation
120-day hospitalisation
120-day nursing home
admission
120-day death
Primary
ISAR screening to identify high-risk
4-month functional
patients + brief standardised geriatric
decline or deathb
nursing assessment
+ team discharge care planning
Secondary
+ community services referrals
1-month ED
re-presentation
Identification of high-risk patients using
Composite (of all
HK-ISAR screening tool
outcomes stated below)
+ standardised assessment of
6-month early return/
functional (Barthel), cognitive (MMSE)
frequent ED visits
and depression (GDS) status
6-month admission to
+ community-based services referrals
hospital
6-month functional
decline (HK-ISAR)
6-month
institutionalisation or
death

5.7% (11.4 to 0.0%)a


2.5% (7.4 to 2.4%)
2.4% (2.7 to 7.5%)
9.9% (17.1 to 2.7%)a
1.0% (2.9 to 4.9%)
0.5% (4.6 to 5.5%)
Reduceda

Reduceda

2.3%
5%
14%a

OR 1.42 (0.952.14)
OR 0.99 (0.641.54)
OR 0.21 (0.050.99)a

OR 2.00 (0.3611.00)
OR 0.9 (0.661.24)
OR 1.05 (0.751.49)
OR 0.4 (0.141.15)
OR 0.89 (0.362.72)
OR 0.53 (0.310.91)a

OR 1.6 (1.02.6)a
Positive (P = 0.299)
0.8%
4.0%
0.04 points
0.2% or 0.0%

Continued

J. A. Lowthian et al.
Table 1. Continued
Study

Setting
population

Study design,
length and year

Comparative
controlled
cohort
12 months
2009/10

2,196

Before/after
12 months
2006/07

487

Intervention elements

Outcomes

Results: % difference or
odds ratio (95% CI)

....................................................................................
Observational studies
Arendts
2 Australian
et al. [38]
EDs
65 years
High- versus
low-risk
patients

Foo et al.
[47]

Guttman
et al. [40]

Mion et al.
[44]

1 Singapore ED
65 years
High-risk
patients

1 Canadian ED
75 years

4 US EDs
65 years
High-risk
patients

Before/after
14 days
1999/00

Before/after
30 days
1997

1,724

Identification of high-/low-risk patients


using ISAR screening tool
+ allied health team assessment/care
coordination for high-risk group
+ post-discharge services referral

Geriatric nurse assessment


+ ED case conference
+ post-discharge services referrals

ED nurse discharge planning


+ tailored management strategies
+ community services referral/liaison
+ phone follow-up at 24 h and 1 week

14,658 Identification of high-risk patients using


TRST screening tool
+ geriatric nursing assessment
+ discharge planning
+ community services linkage within
4872 h of ED discharge

Primary
28-day unplanned ED
re-presentation
Secondary
28-day death
1 year 1 unplanned
hospitalisation
1-year death
3-, 6-, 9- and 12-month
ED re-presentation
3-, 6-, 9- and 12-month
hospitalisation
3-, 6-, 9- and 12-month
death
3-, 6-, 9- and 12-month
BADL and IADL
Primary
14-day unplanned ED
re-presentation
Secondary outcome
14-day unplanned
hospitalisation
30-day ED re-presentation

3%a

0.1%
13.9%a
0.5%
IRR = 0.59 (0.480.71)a
IRR = 0.64 (0.510.79)a
No difference
Cannot be interpreted
3.2%
RR = 0.74 (0.570.96)a

OR 0.92 (0.591.42)
1.4%a

IADL, independent activities of daily living; MSQ, mental status questionnaire; ADL, activities of daily living; BADL, Barthel activities of daily living; MMSE,
mini-mental state examination; GDS, geriatric depression score; HK-ISAR, Hong Kong Identification of Seniors at Risk.
a
Statistically significant.
b
Study population includes small% of patients who were unexpectedly admitted from ED at baseline.

rates increased over time: 0.2% at 14 days [40], 1.3% at 1 and


4 months [38, 43], 10% at 12 months [38] and 15% at 18
months [37], regardless of initial patient risk prole or
whether ED-CTS were provided.

Discussion
A variety of models for care transition have been employed
internationally since the mid-1990s to diminish risk of
adverse outcomes following an ED episode. However, this
systematic review highlights a lack of high-level evidence
about effectiveness of these models due to a very low literature base overall, with few studies using a robust research
evaluation design. The nine studies identied were of variable methodological quality, with only two RCTs evaluated as
having low risk of bias and two observational studies having
a high-quality rating. All studies comprised numerous components of a comprehensive geriatric-focused ED community transition. Such care models have face validity; however,
we have shown limited evidence for effectiveness in reducing
unplanned ED re-attendance, hospital admission or mortality. This is disappointing as it indicates no advancement in
our understanding of the issues since a similar review was

conducted 10 years ago [22], despite addition of more


studies and judicious use of meta-analysis.
A recent meta-analysis by Ellis et al. [48] identied that
provision of inpatient comprehensive geriatric assessment
(CGA) increased the likelihood of living at home (OR 1.16,
95% CI 1.051.28, 18 RCTs; n = 7,062) up to 12 months following discharge and decreased death or functional deterioration up to 12 months (OR 0.76, 95% CI 0.640.90, 5
RCTs; n = 2,622). Components of ED-CTS and CGA are
similar in terms of holistic evaluation with referral and
linkage to community services. Therefore, one would assume
that ED-CTS would facilitate improved patient outcomes.
Methodological issues

Our review and meta-analyses were systematic and rigorous;


however, certain methodological issues preclude us from
identifying evidence for ED-CTS effectiveness. The small
number of RCTs identied is most likely attributed to numerous challenges faced by researchers and clinicians when
designing studies to test multi-faceted interventions in an
uncontrolled real-world environment. While RCTs are
regarded as gold standard, they are not without limitations
in testing complex health service interventions.

Decline in health state and re-attendance in older people following ED discharge

Figure 2. Effect of ED community care transition strategy among RCTs ( primary analysis) and RCTs and observational study (secondary analysis). Weight is the relative contribution of each study to the overall estimate of the treatment effect using a random
effects model.

In addition, included studies had subtle differences.


For example, populations were all older vulnerable patients;
however, they varied in age from 65 to 75 years; and

the focus in some studies was on patients determined by


a screening tool to be at high risk of adverse outcomes
(Table 1).

J. A. Lowthian et al.
Outcomes of interest

The foremost primary outcome was early return to ED or


hospital admission, as effectiveness of hospital-community
transition has historically been determined from a health
system view of care delivery, rather than patient health outcomes such as functional status.
In addition, follow-up periods ranged from 14 days to 18
months, adding another layer of complexity to evaluation of
intervention effects in an older population that continues to
age over time, with multi-faceted health and social care issues.
Conicting effects were reported by two studies, with one
indicating signicant reduction in early ED re-presentation at
14 days [40], while the other showed a signicant increase
up to 30 days [38]. ED re-presentation and hospitalisation
following implementation of ED-CTS may reect improved
surveillance of a cohort considered to be at increased risk.
Alternatively, for patients not at risk, it may suggest other
factors including satisfaction with the care level provided
during and after the visit [40, 43], or condence with the timeliness, quality and safety of the specialised care provided by
EDs compared with that currently available in the community
[49]. In addition, convenience of a 24-h acute care system
cannot be ignored [50, 51].
Future research might consider more patient- and family/
carer-centred outcomes such as independence in ADL, unplanned nursing home transfer or unexpected death; as well
as prevention of adverse events such as delirium, infections,
pressure ulcers and falls; alongside quality of life, patient experience and carer burden/strain. While physical [37, 41, 43,
47] and cognitive [37, 43] functional outcomes were measured in some studies, they were difcult to interpret due to
the variety of tools used and poor reporting. Functional assessment instruments most commonly used in research are
not always responsive to clinically important changes in older
community-dwelling adults [52]. This highlights the imperative for consensus in future research regarding outcomes that
should be measured, how they should be measured and at
what time frames, to help us truly understand the true effects
of future interventions. Such consensus could be achieved
through development of international collaborations.
ED community care transition strategies

Most importantly, ED-CTS are complex health service interventions, comprising multiple components (Supplementary
data, Appendix Table S3, available in Age and Ageing online).
All interventions comprised holistic geriatric assessment with
targeted referral to community services. Such interventions
are necessarily tailored to individual needs, so components
and implementation methods will no doubt vary within and
between individual trials [53]. Inclusion of telephone follow-up
was the differentiating feature of ED-CTS employed by trials
that individually reported signicant reduction in early ED
re-attendance [40] and need for nursing home admission [43];
however, the precise nature of implementation is uncertain.
Strategies including telephone follow-up to conrm ED discharge instructions have been effective in other studies [16, 54].

We also have no information about effectiveness of implementation of any of these complex interventions, which is
a function of age of these studies. Future research should
consider use of hybrid designs that simultaneously assess effectiveness of interventions alongside implementation strategy [55]. Such evaluations generally include quantitative and
qualitative methods to understand barriers and enablers to
implementing the intervention and include process, impact
and outcome assessments. This would enhance understanding of study outcomes [56]. Performing RCTs within settings
whose primary goal is service provision is an ongoing challenge. While clearly this research design is ideal, tensions
remain between traditional methods of service improvement
that are continuous, iterative and incremental, and academic
imperatives to ensure interventions are a priori designed
and implemented in a more static controlled manner, with a
stronger focus on intervention and process delity. There
will need to be increasing engagement of both academics
and service providers in study governance, as well as in intervention design and methods of implementation and evaluation, if these tensions are to be effectively managed.
Strengths and limitations

The strength of this study is use of a systematic search strategy,


with only methodologically rigorous evidence considered. A
limitation is exclusion of studies not meeting strict eligibility
criteria, which may potentially help hypothesis generation.
Although studies of single system illness (e.g. rehabilitation for
fracture) may have some relevance, we focussed on global
multifactorial strategies, because older ED patients typically
have complex underlying biopsychosocial issues requiring a
holistic assessment/management plan. Comparability of study
ndings was limited by study heterogeneity. We included observational studies evaluated to be of high quality; however,
our meta-analyses and interpretation reected issues of potential bias and over-estimation of effect.
Current evidence for ED community care transition strategies is limited. Improved study design to assess efcacy and
effectiveness will be necessary given the imperative of an
ageing population and an environment where there is an increasing focus on appropriate hospital admissions and a
focus on helping older people age in settings that meet their
needs and preferences.

Key points
Care models to support safe discharge from the ED are
complex health service interventions.
Meta-analysis identied no evidence for effectiveness of
current care models.
There are limited published data of high quality on which
to base denitive conclusions.
Hybrid mixed-method designs to simultaneously assess
intervention efcacy and effectiveness should be considered.

Decline in health state and re-attendance in older people following ED discharge

Acknowledgements
The authors thank Lorena Romero (LR), Senior Librarian,
Ian Potter Library @ Alfred Health, for her guidance with
development of the search strategy. They also thank Jessica
Callaghan (JC) for her assistance with the preliminary screening of the initially identied records.

22.

28.

31.

Conflicts of interest
None declared.

32.

Funding

33.

This study is part of a research program entitled Determining


Best Practice for Safe Discharge of the Older Emergency
Patient: Safe Elderly Emergency Discharge (SEED), funded
by the Alfred Research Trusts. J.A.L. is supported by an
NHMRC Early Career Fellowship (1052442); and A.L.B. is
supported by an NHMRC Career Development Fellowship
(1067236).

34.

36.
37.

Supplementary data
Supplementary data mentioned in the text are available to
subscribers in Age and Ageing online.
38.

References
(The very long list of references supporting this review has meant
that only the most important are listed here and are represented
by bold type throughout the text. The full list of references
is given in Supplementary data, available in Age and Ageing
online).
1. Lowthian JA, Jolley D, Curtis AJ et al. The challenges of population ageing: accelerating demand for emergency ambulance
services by older patients: 19952015. MJA 2011; 194: 5748.
2. Lowthian JA, Curtis AJ, Jolley DJ et al. Demand at the ED
front door: ten-year trends in Emergency Department presentations. Med J Aust 2011; 196: 12832.
5. Sanders AB, Witzke D, Jones JS et al. Principles of care and application of the geriatric emergency care model. In: Sanders
AB, ed. Emergency Care of the Elder Person. St Louis:
Beverly Cracom Publications, 1996; 5993.
7. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med
2002; 39: 23847.
20. Banerjee J, Conroy S. Quality Care for Older People
with Urgent and Emergency Care Needs: The Silver Book.
London.
http://www.bgs.org.uk/index.php?option=com_
content&view=category&layout=blog&id=207&Itemid=888.
2012.
21. American College of Emergency Physicians. Geriatric
Emergency Department Guidelines. 2013. American College
of Emergency Physicians, The American Geriatrics Society,
Emergency Nurses Association, and the Society for Academic

39.

40.

41.

42.

43.

44.

45.

46.

Emergency Medicine. http://www.acep.org/geriEDguide


lines/.
Hastings SN, Hein MT. A systematic review of interventions
to improve outcomes for elders discharged from the emergency department. Acad Emerg Med 2005; 12: 97886.
Grimshaw J, Campbell M, Eccles M et al. Experimental and
quasi-experimental designs for evaluating guideline implementation strategies. Fam Pract 2000; 17(Suppl. 1): S116.
Higgins JPT, Green S (eds). Cochrane Handbook for Systematic
Reviews of Interventions. Version 5.1.0 [updated March 2011]. The
Cochrane Collaboration, 2011.
Dickens AP, Richards SH, Greaves CJ et al. Interventions targeting social isolation in older people: a systematic review.
BMC Public Health 2011; 11: 647.
Wells GA, Shea B, OConnell D et al. The Newcastle-Ottawa
Scale (NOS) for assessing the quality of nonrandomized studies
in meta-analyses. Canada: Department of Epidemiology and
Community Medicine, University of Ottawa. http://www.ohri.
ca/programs/clinical_epidemiology/oxford.htm.
Schrier I, Boivin JF, Steele RJ et al. Should meta-analyses of
interventions include observational studies in addition to randomized controlled trials? A critical examination of underlying
principles. Am J Epidemiol 2007; 166: 12039.
Higgins JP, Thompson SG, Deeks JJ et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 55760.
Caplan GA, Williams AJ, Daly B et al. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the
emergency department--the DEED II study. J Am Geriatr Soc
2004; 52: 141723.
Arendts G, Fitzhardinge S, Pronk K et al. Outcomes in older
patients requiring comprehensive allied health care prior to discharge from the emergency department. Emerg Med Australas
2013; 25: 12731.
McCusker J, Dendukuri N, Tousignant P et al. Rapid two-stage
emergency department intervention for seniors: impact on
continuity of care. Acad Emerg Med 2003; 10: 23343.
Guttman A, Alalo M, Guttman R et al. An emergency
department-based nurse discharge coordinator for elder
patients: does it make a difference? Acad Emerg Med 2004;
11: 131827.
McCusker J, Verdon J, Tousignant P et al. Rapid emergency department intervention for older people reduces risk of functional decline: results of a multicenter randomized trial. J Am
Geriatr Soc 2001; 49: 127281.
McCusker J, Jacobs P, Dendukuri N et al. Cost-effectiveness of
a brief two-stage emergency department intervention for highrisk elders: results of a quasi-randomized controlled trial. Ann
Emerg Med 2003; 41: 4556.
Mion LC, Palmer RM, Meldon SW et al. Case nding and referral model for emergency department elders: a randomized
clinical trial. Ann Emerg Med 2003; 41: 5768.
Mion LC, Palmer RM, Anetzberger GJ et al. Establishing a
case-nding and referral system for at-risk older individuals in
the emergency department setting: the SIGNET model. J Am
Geriatr Soc 2001; 49: 137986.
Runciman P, Currie CT, Nicol M et al. Discharge of elderly
people from an accident and emergency department:
evaluation of health visitor follow-up. J Adv Nurs 1996; 24:
7118.
Yim VW, Rainer TH, Graham CA et al. Emergency department
intervention for high-risk elders: identication strategy and

J. A. Lowthian et al.
randomised controlled trial to reduce hospitalisation and institutionalisation. Hong Kong Med J 2011; 17(3 Suppl. 3): 47.
47. Foo CL, Siu VW, Tan TL et al. Geriatric assessment and intervention in an emergency department observation unit reduced
re-attendance and hospitalisation rates. Australas J Ageing
2012; 31: 406.
48. Ellis G, Whitehead MA, Robinson D et al. Comprehensive geriatric assessment for older adults admitted to hospital: metaanalysis of randomised controlled trials. BMJ 2011; 343: d6553.
49. Lowthian JA, Smith C, Stoelwinder JU et al. Why older patients
of lower clinical urgency choose to attend the Emergency
Department. Int Med J 2013; 43: 5965.

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53. Glasziou PP, Chalmers I, Green S et al. Intervention synthesis:


a missing link between a systematic review and practical treatment(s). PLoS Med 2014; 11: e1001690.
55. Curran GM, Bauer M, Mittman B et al. Effectivenessimplementation hybrid designs: combining elements of clinical
effectiveness and implementation research to enhance public
health impact. Med Care 2012; 50: 21726.
56. Craig P, Dieppe P, MacIntyre S et al. Developing and Evaluating
Complex Interventions. UK: Medical Research Council, 2008.
Received 23 November 2014; accepted in revised form
15 May 2015