165 'What Matters' in the Emergency Department: Older Adults' Desires and Clinicians' Beliefs

Abstract

One model germane to ED geriatric care is the 4Ms model – What Matters, Medications, Mentation, and Mobility – developed via the Age-Friendly Health Systems initiative. A feasible approach to identifying ‘What Matters’ in the ED is lacking. Therefore, we sought to describe older adult patient priorities when seeking emergency care and to identify the anticipated disposition concordance with their treating clinicians. We conducted a qualitative and quantitative analysis of cognitively intact patients aged 65 years and older receiving care in two EDs and their treating clinicians. Stakeholders previously developed the ‘What Matters in the ED’ structured conversation guide to explore patients’ concerns and expectations; a question about anticipated disposition was added. Participants were interviewed during the ED encounter when disposition uncertainty still existed. The first question ascertained patients’ concerns and fears about their health and healthcare; the second question identified the outcome patients most wanted from their ED visit. The final question asked, “Do you believe that hospitalization will help you today? If so, why?” We asked analogous structured questions to the patient’s treating clinician regarding the patients’ priorities. Interviews were professionally transcribed and an inductive approach of thematic analysis was used by two authors (CJG, HD) to line-by-line review and analyze interview data. We created a code key, grouped codes into themes, and maintained an audit trail of all analytic decisions. Of the 51 patients approached, 40 persons aged 65+ and their emergency clinicians completed interviews. Patient interviews ranged in time from 1 to 8 minutes (mean - 2 minutes, 50 seconds). Three major themes among participants included: 1) Older adults seeking emergency care were concerned regarding preservation of current status, contributing factors related to chronic conditions, and symptom resolution, whereas clinicians almost exclusively referenced the chief complaint as the patient’s greatest concern, 2) Older adults valued diagnosis and symptom resolution, followed closely by their ability to ‘go home’ as outcomes sought, with clinicians also commonly identifying disposition as a primary concern to the older adult, and 3) Older adults often believed that hospital admission was warranted, whereas clinicians often felt that discharge was the appropriate disposition. Quantitatively, patient-clinician anticipated disposition concordance was present in 60% of encounters (Cohen’s kappa coefficient 0.217), suggesting fair agreement. Older adults identified several concerns regarding their health in comparison to their treating clinicians, suggesting emergency clinicians may be unaware of certain patient priorities during the encounter. Despite often being in alignment with desired patient outcomes, older adults and clinicians exhibited only fair agreement in anticipated disposition. This work identifies the feasibility of incorporating the ‘What Matters’ questions in the ED, and the importance of aligning emergency care with the value-based priorities of older adults.