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ObjectivesWe aimed to describe emergency department (ED) care transition interventions delivered to older adults with cognitive impairment, identify relevant patient-centered outcomes, and determine priority research areas for future investigation.DesignSystematic scoping review.Setting and participantsED patients with cognitive impairment and/or their care partners.MethodsInformed by the clinical questions, we conducted systematic electronic searches of medical research databases for relevant publications following published guidelines. The results were presented to a stakeholder group representing ED-based and non-ED-based clinicians, individuals living with cognitive impairment, care partners, and advocacy organizations. After discussion, they voted on potential research areas to prioritize for future investigations.ResultsFrom 3848 publications identified, 78 eligible studies underwent full text review, and 10 articles were abstracted. Common ED-to-community care transition interventions for older adults with cognitive impairment included interdisciplinary geriatric assessments, home visits from medical personnel, and telephone follow-ups. Intervention effects were mixed, with improvements observed in 30-day ED revisit rates but most largely ineffective at promoting connections to outpatient care or improving secondary outcomes such as physical function. Outcomes identified as important to adults with cognitive impairment and their care partners included care coordination between providers and inclusion of care partners in care management within the ED setting. The highest priority research area for future investigation identified by stakeholders was identifying strategies to tailor ED-to-community care transitions for adults living with cognitive impairment complicated by other vulnerabilities such as social isolation or economic disadvantage.Conclusions and implicationsThis scoping review identified key gaps in ED-to-community care transition interventions delivered to older adults with cognitive impairment. Combined with a stakeholder assessment and prioritization, it identified relevant patient-centered outcomes and clarifies priority areas for future investigation to improve ED care for individuals with impaired cognition, an area of critical need given the current population trends.

Background: Academic emergency medicine (EM) is foundational to the EM specialty through the development of new knowledge and clinical training of resident physicians. Despite recent increased attention to the future of the EM workforce, no evaluations have specifically characterized the U.S. academic EM workforce. We sought to estimate the national proportion of emergency physicians (EPs) identified as academic and the proportion of emergency department (ED) visits that take place at academic sites. Methods: We performed a cross‐sectional analysis of EPs and EDs using data from the American Hospital Association, the Centers for Medicare & Medicaid Services, and Doximity's Residency Navigator. EPs were identified as "academic" if they were affiliated with at least one facility determined to be academic, defined as EDs officially designated by the Accreditation Council for Graduate Medical Education (ACGME) as clinical training sites at accredited EM residency programs. Our primary outcomes were to estimate the national proportion of EPs identified as academic and the proportion of ED visits performed at academic sites. Results: Our analytic sample included 26,937 EPs practicing clinically across 4920 EDs and providing care during 130,471,386 ED visits. Among EPs, 11,720 (43.5%) were identified as academic, and among EDs, 635 (12.9%) were identified as academic sites, including 585 adult/general sites, 45 pediatric‐specific sites, and 10 sites affiliated with the Department of Veterans Affairs. In 2021, academic EDs provided care for 42,794,106 ED visits or 32.8% of all ED visits nationally. Conclusions: Approximately four in 10 EPs practice in at least one clinical training site affiliated with an ACGME‐accredited EM residency program, and approximately one in three ED visits nationally occur in these academic EDs. We encourage further work using alternative definitions of an academic EPs and EDs, along with longitudinal research to identify trends in the workforce's composition. [ABSTRACT FROM AUTHOR]

Background: Patient‐reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care. Methods: With the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science‐Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post–emergency care time period. Independent reviewers performed title/abstract review, full‐text screening, data extraction, study characteristic summarization, and risk‐of‐bias (RoB) assessments. Results: Our search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1–3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4–6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality. Conclusions: PROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit. [ABSTRACT FROM AUTHOR]

Background: Emergency care workforce concerns have gained national prominence given recent data suggesting higher than previously estimated attrition. With little known regarding characteristics of physicians leaving the workforce, we sought to investigate the age and number of years since residency graduation at which male and female emergency physicians (EPs) exhibited workforce attrition. Methods: We performed a repeated cross‐sectional analysis of EPs reimbursed by Medicare linked to date of birth and residency graduation date data from the American Board of Emergency Medicine for the years 2013–2020. Stratified by gender, our primary outcomes were the median age and number of years since residency graduation at the time of attrition, defined as the last year during the study time frame that an EP provided clinical services. We constructed a multivariate logistic regression model to examine the association between gender and EP workforce attrition. Results: A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included. During the study years, 5905 male EPs exhibited attrition at a median (interquartile range [IQR]) age of 56.4 (44.5–65.4) years, and 2463 female EPs exhibited attrition at a median (IQR) age of 44.0 (38.0–53.9) years. Female gender (adjusted odds ratio 2.30, 95% confidence interval 1.82–2.91) was significantly associated with attrition from the workforce. Male and female EPs had respective median (IQR) post–residency graduation times in the workforce of 17.5 (9.5–25.5) years and 10.5 (5.5–18.5) years among those who exhibited attrition and one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation. Conclusions: Female physicians exhibited attrition from the EM workforce at an age approximately 12 years younger than male physicians. These data identify widespread disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce. [ABSTRACT FROM AUTHOR]

The growing number of people living with dementia (PLWD) requires a coordinated clinical response to deliver pragmatic, evidence‐based interventions in frontline care settings. However, infrastructure to support such a response is lacking. Moreover, there are too few researchers conducting rigorous embedded pragmatic clinical trials (ePCTs) to make the vision of high quality, widely accessible dementia care a reality. National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's disease and Related Dementias Clinical Trials (IMPACT) Collaboratory seeks to improve the pipeline of early career researchers qualified to lead ePCTs by funding career development awards. Even with support from the Collaboratory, awardees face practical and methodological challenges to success, recently exacerbated by the COVID‐19 pandemic. We first describe the training opportunities and support network for the IMPACT CDA recipients. This report then describes the unique career development challenges faced by early‐career researchers involved in ePCTs for dementia care. Topics addressed include challenges in establishing a laboratory, academic promotion, mentoring and professional development, and work‐life balance. Concrete suggestions to address these challenges are offered for early‐career investigators, their mentors, and their supporting institutions. While some of these challenges are faced by researchers in other fields, this report seeks to provide a roadmap for expanding the work of the IMPACT Collaboratory and initiating future efforts to recruit, train, and retain talented early‐career researchers involved in ePCTs for dementia care. [ABSTRACT FROM AUTHOR]

The article presents a study which described emergency department (ED) clinician attitudes after implementation of the Advanced Practice Registered Nurse (APRN) led geriatric emergency medicine service (GEMS) consult service in a large academic health center. Topics include percentage of older adults that comprised the annual ED visits, GEMs consult model, and results of clinician satisfaction survey.

Background: Advanced practice providers (APPs) comprise an increasing proportion of the emergency medicine (EM) workforce, particularly in rural geographies. With little known regarding potential expanding practice patterns, we sought to evaluate trends in independent emergency care services billed by APPs from 2013 to 2019. Methods: We performed a repeated cross‐sectional analysis of emergency clinicians independently reimbursed for at least 50 evaluation and management (E/M) services (99281–99285, 99291) from Medicare Part B, with high‐acuity services including Codes 99285 and 99291. We describe the outcome proportion of E/M services by acuity level and report at (1) the encounter level and (2) at the clinician level. We stratified analyses by clinician type and geography. Results: A total of 47,323 EM physicians, 10,555 non‐EM physicians, and 26,599 APPs were included in analyses. APPs billed emergency care services independently for 5.1% (rural 7.3%, urban 4.8%) of all high‐acuity encounters in 2013, increasing to 9.7% (rural 16.4%, urban 8.8%) by 2019. At the clinician level, in 2013, the average rural‐practicing APP independently billed 22.8% of services as high acuity, 72.6% as moderate acuity, and 4.5% as low acuity. By 2019, the average rural‐practicing APP independently billed 36.2% of services as high acuity, representing a +58.8% relative increase from 2013. Relative increases in high‐acuity visits independently billed by APPs were substantially greater when compared to EM physicians across both rural and urban geographies. Conclusions: In 2019, APPs billed independent services for approximately one in six high‐acuity ED encounters in rural geographies and one in 11 high‐acuity ED encounters in urban geographies, and well over one‐third of the average APPs' encounters were for high‐acuity E/M services. Given differences in training and reimbursement between clinician types, these estimates suggest further work is needed evaluating emergency care staffing decision making. [ABSTRACT FROM AUTHOR]

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 used a health claims database from 2017-2018 of those treated for TD. Descriptive statistics and logistics regression models were used to characterize trends. Results: We included in this analysis 115,885 claims from 108,111 unique individuals (93.29%) with 7,774 (6.71%) return claims within 28 days. Of the return claims, 470 (6.05%) were to the ED. Emergency clinicians offered no oral corticosteroid prescription 5.27% (n = 3,194) of the time; 3276 (86.26%) prescriptions were for a duration of 1-13 days, 410 (10.80%) were for 14-20 days, and 112 (2.95%) were for >21 days. Further, we found that shorter duration oral corticosteroids (odds ratio [OR] 1.30; 95% confidence interval 1.17-1.44; P <0.001) and initial treatment for TD at the ED compared to primary care clinicians (OR 0.87 [0.80, 0.96]; P <0.001) and other non-dermatologists (OR 0.89 [0.80, 0.98]; P = 0.01) places patients at an increased risk for return visits with healthcare clinicians when controlling for drug group, duration of treatment, and initial treatment location. Conclusion: Despite recommendations to treat TD with oral steroids for at least 14 days, most emergency clinicians offered this treatment for shorter durations and was associated with return visits. Emergency clinicians should consider treatment of two to three weeks when providing systemic steroid coverage when there are no limiting contraindications, especially as patients who present to the ED may do so with more severe disease. Additional education may be needed on appropriate treatment pathways for TD to reduce healthcare utilization associated with undertreatment. [ABSTRACT FROM AUTHOR]