Administration of Emergency Medicine

doi:10.1016/j.jemermed.2005.07.008 The Journal of Emergency Medicine, Vol. 30, No. 4, pp. 455 460, 2006 Copyright 2006 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/06 $ see front matter Administration of Emergency Medicine OLDER ADULTS IN THE EMERGENCY DEPARTMENT: PREDICTING PHYSICIANS BURDEN LEVELS John G. Schumacher, PhD,* Gary T. Deimling, PhD, Stephen Meldon, MD, and Bert Woolard, MD *Department of Sociology and Anthropology, University of Maryland, Baltimore County, Baltimore, Maryland, Department of Sociology, Case Western Reserve University, Cleveland, Ohio, Emergency Medicine Department, MetroHealth Hospital, Cleveland, Ohio, and Emergency Medicine Department, Brown University, Providence, Rhode Island Reprint Address: John G. Schumacher, PhD, Department of Sociology and Anthropology, UMBC, 1000 Hilltop Circle, Baltimore, MD 21250 e Abstract The aging of the U.S population will have impact on hospital Emergency Departments (ED) nationwide. To date, ED research has focused on utilization rates and acuity without considering issues of burden and stress that emergency physicians may experience caring for the increasing numbers of older adult patients. Results of a survey of Emergency Medicine residents and their attendings indicates that physicians overestimate the percentage of their patient load aged 65 years and older, have less confidence managing older patients, and desire more geriatric Emergency Medicine training. Based on regression analysis, several factors predict higher levels of emergency physician burden including training level, experiences, patient census estimate gaps, and relational issues with patients. Findings suggest the need to systematically address how the profession of Emergency Medicine is responding to its growing older adult patient population. 2006 Elsevier Inc. e Keywords burden; elder; stress; burnout INTRODUCTION During the next 30 years, the U.S. population of age 65 years and older citizens will double from 34 million in 2000 to over 69 million in the year 2030 (1). This dramatic aging of the U.S. population will cause a significant impact upon a range of social institutions from education to health care, including hospital emergency departments (EDs). Visits to EDs have increased over the past 20 years, exceeding 103 million visits in 2000, with older adults representing about 18% or 18.5 million visits annually (2). To date, research on older adults in this setting has been dominated by descriptive studies analyzing utilization rates and issues such as acuity levels, repeat visits, and 6-month mortality rates (3,4). Older adults have been shown to present with: nonstandard disease presentations, altered laboratory values, multiple co-morbid diseases, extensive medical histories, communication problems, altered mental status, and the absence of classic diagnostic symptoms (5 7). Research on the encounter between emergency physicians (EPs) and older patients has received much less attention. McNamara and colleagues reported that when surveyed, a majority of EPs agreed that older adults require more time and resources than other patients and that their training in geriatric Emergency Medicine is not sufficient (8). Emergency Medicine has been described as a high stress work environment due to its unpredictability and the need for rapid action and decision-making (9). Increasing numbers of encounters with older ED patients has the potential to add to physician stress and burden because these patients may be more time consuming, RECEIVED: 30 June 2004; FINAL SUBMISSION RECEIVED: 20 April 2005; ACCEPTED: 25 July 2005 455

456 J. G. Schumacher et al. perceived as less satisfying, and EPs report less confidence in their treatment (8). Despite a decade-old call for research into factors associated with occupational stress among EPs, few studies examine this issue and none has focused on the impact of older adult patients (10). The purpose of this study was to systematically collect selfreport data regarding the experiences, attitudes, and perceived burden related to treating older adult patients. MATERIALS AND METHODS Study Design and Population A mailed survey design was used and the study was approved by the institutional review board. The study population included all Emergency Medicine residents and attending physicians working in the eight residency training programs in New England. Table 1. Demographic Characteristics of the Sample (n 163) Mean SD n % Age (years) 34.94 8.27 Race White 139 86.3 Black 0 0 Asian 16 9.9 Hispanic 4 2.5 Other 4 1.2 Gender Male 127 77.9 Female 36 22.1 Training level Resident 94 57.7 Attending 69 42.3 for reliability using Cronbach alpha. Multiple regression analysis using SPSS 12.0 software was used to determine significant predictor variables of the dependent variable (11). Study Content and Administration The survey questions were designed to measure the EP s experiences, perceptions, and attitudes related to treating older adults. Socio-demographic variables included age, gender, race, and training level (resident/attending). Practice environment variables asked respondents to estimate the overall census of the ED as well as to estimate the percentage of their own patient load aged 65 years and older. In addition, respondents were asked to identify the percentage of older adult patients they would prefer to see in the ED. Barriers to the care of the older adults were measured with a series of Likert questions and respondents were also asked to rate their confidence treating pediatric, elderly, and adult patients. Three questions asked about the training received to treat older patients and one question asked about the respondent s overall experience with elderly patients in their training. The respondent s level of burden (dependent variable) was measured with the EP Burden of Care scale, which was based on questions modified from existing burden, job satisfaction, and burnout measures. All attending and resident physicians listed on the residency training rosters as of August 1, 1999 were included in the mailing. All surveys returned by October 1, 1999 were included in the data analysis. Data Analysis The study utilized univariate analysis for sample description and question description. Composite variables and scales were developed using factor analysis and tested Sample Description RESULTS The final sample was comprised of n 163 out of N 411 surveys for a 40% response rate. Demographics appear in Table 1. Respondents were primarily male (77.9%), white (86.3%), and had a mean age of 34.9 years. In terms of training level, the final sample was 57.7% residents and 42.3% attending physicians. Over 90% of the respondents worked in departments with a census exceeding 45,000 patients per year. Univariate Analysis Estimate gap. Regarding the treatment of older adults, one question asked respondents to estimate the percentage of their patient load that is 65 years and older. The mean estimate for the sample was 39.4%. A later question asked respondents to list the percentage of patients they would prefer to be age 65 and older. The mean preferred percentage was: 29.3%. The actual percentage of patients aged 65 and older, based on each hospital s ED admission records, ranged from 11.6% to 23.0%. Confidence managing patients. In terms of confidence managing patients, respondents were asked to rate their confidence (on a 10-point scale from 1 not at all confident to 10 extremely confident) for pediatric, elderly, and adult patients. The mean confidence levels were: pediatric 6.64, elderly 7.56, adult 8.47.

Older Adults in the ED: EP Burden 457 Table 2. Means and Standard Deviations on Scales Relational challenge composite How much do the following prevent you from doing as much as you would like for your elderly ED patients? 1. Communication difficulties with patient 2. Cognitive impairment with elderly Mean Training experiences. Several questions asked about training experiences regarding older adult patients. Close to 90% of respondents said that they had treated many SD 2.91.94 3.15.94 patients 3. Lack of rapport with elderly patients 1.61.81 Cronbach alpha:.71 5-point Likert scale: 1 not at all, 2 a little, 3 some, 4 much, 5 very much Emergency Physician Burden of Care scale 1. I feel that my elderly patients are overly demanding to care for. 2. I feel that as a result of caring for my elderly patients, I do not have enough time for my other patients. 3. I feel that caring for my elderly patients disrupts my routine practice in the ED. 4. I feel that caring for elderly patients in the ED is too expensive. 5. Caring for elderly patients in the ED makes me depressed. 6. It is difficult to treat elderly patients because it takes so much time. Cronbach alpha:.86 5-Point Likert Scale: 1 strongly disagree, 2 disagree, 3 neutral, 4 Agree, 5 Strongly Agree 2.25.85 2.27.82 2.10.75 2.32.96 2.12.90 2.69 1.03 complicated older patients in the course of their training. Based on that experience, 78.4% of respondents agreed that more training is needed to provide better care to elderly patients. In addition, 25.7% of respondents indicated that the majority of their training avoided instruction in geriatric Emergency Medicine. Finally, when asked to rate their first-hand experience with elderly patients during their medical training (on a 10-point anchored scale with 1 extremely negative and 10 extremely positive), the mean response was 7.33. Relational challenges and EP Burden of Care scales. Table 2 lists the individual survey questions that were combined to create: 1) the Relational Challenge scale, and 2) the EP Burden of Care scale. The scales were pilot tested on two independent groups of EPs before inclusion in this survey. The Relational Challenge scale questions focused on issues that impair the physician-patient relationship and communication with patients. The Cronbach alpha reliability for the scale was alpha.71. The EP Burden of Care scale was modified from existing scales in the areas of caregiver burden, job stress and burnout, and had an alpha reliability of alpha.86. Table 3 shows the zero-order correlation matrix among the study variables. The EP Burden scale is negatively correlated with respondent age (r.22) and training level (r.25). Burden increases, as age and training level decrease. Higher rated experience with the elderly is negatively related to burden (r.43). Burden is positively correlated with agreement that lack of reimbursement for social issues is a barrier to care (r.25). Burden is also positively related to a larger gap between estimated and actual ED census for older pa- Table 3. Zero-Order Correlation Matrix R Age R Gender Training level 0 Resident 1 Attending Rating experience with elderly in ED No reimbursement for social issues Estimated % minus actual % older patients Relational challenge composite Respondent age Respondent gender.18* Training level 0 Resident/1.76**.19 Attending Rating experience with.26**.02.17* elderly in ED No reimbursement for social.16*.04.21**.01 issues Estimated % minus actual %.25**.01.17*.34.01 older patients Relational challenge.15.11.10.23.25**.22** composite EP Burden Scale.22**.03.25**.43.25**.46**.41** * p 0.05; ** p 0.01.

458 J. G. Schumacher et al. Table 4. Regression Coefficient Table Independent variables tients (r.46) and higher reported relational challenge with elderly patients (r.41). Multivariate analysis. Multiple regression was used to test the path model predicting the burden of care reported by EPs treating elderly patients (Table 4). Independent variables included demographic variables, training level, experience with elderly patients, a barrier to care variable, estimated minus actual elderly patient census variable, and a relational challenge variable. The analysis used EP Burden of Care as the dependent variable that was regressed on the predictor variables listed above. Statistically significant predictor variables included training level (beta.26), experience with elderly (beta.28), no reimbursement (beta.24), estimated older adult census minus actual census (beta.29), and relational challenge (beta.24). This model had an MR 2 of.47 explaining 47% of the observed variance in the model. DISCUSSION EP Burden of Care B Beta p Value Respondent age.06.107 0.29 Respondent gender.28.03 0.66 Training level 2.20.26 0.01 0 Resident/1 Attending Rating experience with elderly.85.28 0.001 in ED No reimbursement for social 1.04.24 0.001 issues Estimated % minus actual %.08.29 0.001 older patients Relational challenge composite.45.24 0.001 MR 2.47, p 0.001 This research examines EPs reports of the burden of care associated with treating elderly patients. The model tested had substantial explanatory power with five significant predictors of similar magnitude. Emergency Medicine resident physicians reported significant levels of burden compared with their attending physician counterparts. In addition, respondents reporting poorer experiences with the elderly during their training also reported higher levels of burden treating elderly patients. This finding suggests that monitoring an EP s experience with elderly patients during their training may be an important way to subsequently reduce levels of burden experienced. In terms of the barrier, no reimbursement for social issues, higher burden was associated with the belief that no reimbursement was a barrier to care for the elderly. Increased burden was also associated with a higher gap between estimated elderly and average elderly ED census. Those EPs who most grossly overestimated this gap had higher levels of burden. Finally, EPs who reported higher levels of relational challenges also reported higher levels of burden. Estimation gap. A significant finding of this research is the exceptional degree to which respondents overestimated the number of older adults treated in their EDs. As noted above, the actual percentage of older adults in the study hospitals EDs ranged from 11.6% to 23.0%. However, the EPs in this study estimated the mean percentage of their older ED patients at 39.4% nearly double the actual percentage they treated. Apparently, older adult patients disproportionately influence the perception of EPs to the extent that they report treating them in much larger numbers than is actually the case. Such overestimation may contribute or indicate feelings of burden, particularly if these patients are also considered to be unsatisfying and time-consuming cases. Further research regarding this estimation gap would be useful to determine the impact that such overestimation has on the practice of Emergency Medicine and elder patient care. Confidence managing patients. Respondents report having the highest confidence treating adult patients (18 64 years) and the lowest confidence treating pediatric patients (0 17 years). Older adult patients aged 65 years and older fall between these two extremes. The mean confidence level for managing each of these populations is significantly different from each other. The fact that the EPs are not equally confident of their patient management indicates that EPs reliably discriminate among the three populations in terms of the care provided. The lack of uniformity of confidence suggests that additional training and education may be desirable for increasing confidence levels for both pediatric and older adult populations. Geriatric training experience. One quarter of the respondents indicated that their training experience avoided instruction in geriatric emergency medicine. It is alarming that respondents interpret their training as avoiding instruction in geriatric Emergency Medicine because as the older adult population increases, the number of elders utilizing Emergency Medicine will grow. However, 78% of respondents agreed that more training in geriatric Emergency Medicine is necessary to provide better care to older adults. Post-graduate training programs should lead the effort in teaching geriatric Emergency Medicine. There should be additional efforts by professional organizations to develop and disseminate educational programs

Older Adults in the ED: EP Burden 459 in geriatric medicine through continuing education, conferences, web-based learning, and other educational means. EP Burden of Care scale. The EP Burden of Care scale is a reliable scale consisting of 6 items representing the concept of burden experienced related to treating older adults. Using a set of predictor variables and multiple regression analysis, which simultaneously controls for all of the predictor variables, the burden experienced by EPs was significantly predicted by training level, experience with elderly patients, reimbursement concerns, estimated elderly patient census, and relational challenge with older patients. The results suggest that residency training is a critical time to address the burden experienced by residents treating older patients. Each of the significant predictors of burden could be subject to influence by residency programs or professional organizations. EM residents reported significantly higher levels of burden than their attending physician counterparts. Thus, attending physicians may want to pay particular attention to the issue of perceived burden experienced by residents in their training programs. Also related to training, physicians who reported better experiences with elderly patients as part of training reported lower overall levels of burden. Thus, residency programs may elect to proactively evaluate their residents experiences with older patients to identify and perhaps intervene in cases where residents are reporting negative experiences with elderly patients. In terms of barriers to care of older adult patients, EPs report that the lack of reimbursement for addressing social issues contributes to feelings of burden. Older adults, as a patient population, may potentially have more social issues associated with their care (e.g., discharge disposition, cognitive impairment, mobility issues). The lack of reimbursement for dealing with these social issues may contribute to increased feelings of burden associated with older patients. The estimation gap is also a predictor of burden. The wider the gap between estimated and actual, the greater the burden reported. Training programs could educate physicians about the actual numbers that may correct their misperceptions. This may decrease the sense of burden. Relational challenge is the final significant predictor that may be influenced by training. EPs report the more challenge they feel relating to a patient, the more burden they experience. Training programs are in the ideal position to teach residents how to respond to challenging situations and to develop adaptive skills to improve relations with patients and reduce their own stress. Overall, examining EP physician perspectives on patient encounters is important because these patient encounters have been identified as a key source of satisfaction and dissatisfaction for physicians across specialties (12). Physicians report the highest levels of practice satisfaction based on patient-related factors such as: 1) challenge of diagnosis, 2) patient diversity, and 3) helping people (13). In contrast, practice dissatisfaction has been associated with abusive and demanding patients, anger on the part of patients or relatives, and difficult or violent patients (13). Considering these dimensions of EP satisfaction and dissatisfaction, older adult patients admitted from nursing homes or presenting with cognitive impairment overlays are at risk of being considered particularly unsatisfying patients. LIMITATIONS AND FUTURE QUESTIONS These data are limited by the relatively small sample size and the focus on academic programs in the Northeast. A survey of community practice EPs might result in different findings. The response rate of 40% is relatively poor and could represent a source of bias for these findings. However, the magnitude of the current findings suggests the results are reliable. A larger sample of physicians would permit a more sophisticated psychometric evaluation of the scale. Confirmatory factor analysis and testing on larger, more diverse samples is the next step. Additional research may focus specifically on physicians-in-training who may experience increased levels of burden associated with treating older patients. CONCLUSIONS Although the majority of EPs in this study report treating many complicated elderly patients in their training, over three-quarters agree that additional education is necessary to improve the quality of care. The need for more education and research about older adults in the ED remains a consistent theme that merits a sustained, focused effort led by the profession of Emergency Medicine. Based on census data, Emergency Departments can anticipate continued growth in the number of older adult patients. Our research demonstrates the feasibility of measuring the issue of burden among EPs in connection with their treatment of older patients. Early identification of feelings of burden would help to target educational programs and the development of interventions to improve the care of older adults. Such programs are indicated considering the significant over-estimations of older adult patient loads endorsed by EPs in this study. Clearly, geriatric Emergency Medicine remains an area demanding attention on both the clinical and academic fronts.

460 J. G. Schumacher et al. Acknowledgment This research was supported by a University of Maryland, Baltimore County, Faculty Research Fellowship, #2003. REFERENCES 1. U.S. Bureau of the Census. Current population survey. Washington, DC: U.S. Government Printing Office; 2003. 2. American Hospital Association. Hospital statistics. Chicago, IL. American Hospital Association; 2000. 3. Aminzadeh F, Dalziel W. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 2002;39:238 47. 4. Strange G, Chen E. Use of emergency departments by elder patients: a five-year follow-up study. Acad Emerg Med 1998;5:1157 62. 5. McDonald A, Abrahams ST. Social emergencies in the elderly. Emerg Med Clin North Am 1990;8:443 59. 6. Sanders A. Emergency care of the elder person. St. Louis, MO. Beverly Cracom; 1996. 7. Eliastam M. Elderly patients in the emergency department. Ann Emerg Med 1989;18:1222 9. 8. McNamara R, Rousseau E, Sanders A. Geriatric emergency medicine: a survey of practicing emergency physicians. Ann Emerg Med 1992;796 801. 9. Wiley J, Fuchs S, Brotherton S, et al. A comparison of pediatric emergency medicine and general emergency medicine physicians practice patterns: results from the future of pediatric education II survey of sections project. Pediatr Emerg Care 2002;18:1179 87. 10. Taliaferro E. Too stressed out to care? Ann Emerg Med 1989;18: 164 5. 11. SPSS for Windows base system user s guide, release 12.0. Chicago, IL. SPSS Inc.; 2003. 12. Richardson A, Burke R. Occupational stress and job satisfaction among physicians: sex differences. Soc Sci Med 1991;33:1179 87. 13. Doan-Wiggins L, Zun L, Cooper M-A, Myers D, Chen E. Practice satisfaction, occupational stress, and attrition of emergency room physicians. Acad Emerg Med 1995;2:556 63.