Quality Appraisal of 

“Strategies to improve care for older adults in the emergency department: a systematic review”

 (2024)

Article Summary

The article “Strategies to improve care for older adults who present to the emergency department: a systematic review” was published in 2024 by Luke Testa, Lieke Richardson, Colleen Cheek et al. (with Kate Churruca and Robyn Clay-Williams among the authors). The review’s objective was to synthesize strategies and interventions used to improve care delivery for older adults (age ≥65) in emergency departments (EDs) and examine their impact on patient outcomes, patient experience, staff experience, and system performance. In conducting this review, the authors searched multiple databases from inception to December 2022. They included studies meeting specific criteria (older ED patient population, an intervention to improve care and reporting the aforementioned outcomes). A total of 76 studies were included, spanning a range of countries (including Australia, US, UK, Canada, and others). The review thus provides a broad look at how ED care for older adults has been improved and what effect those improvements have had.

Quality Appraisal (Using AMSTAR 2 Criteria)

Using the AMSTAR 2 tool (a standardized critical appraisal checklist for systematic reviews) to evaluate this article’s quality, we find that the review was conducted with generally high methodological rigor. Key domains are appraised below:

• Focused Question & Inclusion Criteria: The review addressed a clearly defined question about improving ED care for older adults, specifying its Population, Intervention, and Outcomes of interest. It targeted patients aged 65 and over in the ED, examined “improvement interventions” in that setting, and required that studies report at least one relevant outcome (patient health outcomes, patient experience, staff experience, or ED system performance). These inclusion criteria show a well-framed scope covering all important outcome domains for older persons in the ED (aligning with the “quadruple aim” of health outcomes, patient experience, staff experience, and system metrics). Such clarity in the review question and criteria establishes a strong foundation.
• Protocol and Reporting Standards: The authors followed a pre-specified protocol and reported the review in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines . Notably, the protocol was registered prospectively in PROSPERO , which indicates that the review methods were established in advance. Adherence to PRISMA and protocol registration are strengths because they promote transparency and reduce the risk of selective reporting or methodological bias.
• Literature Search: The literature search was extensive and systematic. The team developed a broad search strategy with a research librarian’s input and searched at least four major databases (CINAHL, Embase, Medline, and Scopus) from their inception up to December 2022 . The search terms were intentionally broad to capture all relevant articles about ED care improvements for older adults . This comprehensive strategy makes it likely that the review identified the majority of relevant studies. However, a minor limitation is that the search was restricted to English-language, peer-reviewed publications . No non-English studies or gray literature (unpublished reports) were included, which the authors acknowledge could exclude valuable data and limit the generalizability of findings . Despite that restriction, the overall search approach was robust for published literature.
• Study Selection and Data Extraction: The review implemented strong measures to minimize bias in selecting and extracting data from studies. After removing duplicates, two reviewers independently screened each study abstract against the inclusion criteria, and then two reviewers independently reviewed the full texts of potentially eligible articles . Any screening disagreements were resolved through discussion or with a third reviewer’s input . Similarly, data extraction was performed in duplicate: two reviewers independently extracted key data on study characteristics, interventions, and outcomes using a standardized form . These paired review processes ensure that the study selection was reliable and that data were accurately captured, reducing the risk of errors or subjective bias influencing the results.
• Study Design Inclusion: The review did not unnecessarily limit the types of studies eligible, which is appropriate given the topic area. The authors included a broad range of study designs – from randomized controlled trials (RCTs) to quasi-experimental before-and-after studies, cohort studies, case–control, and even qualitative studies – so long as they met the basic inclusion criteria . In fact, of the 76 studies included, only 9 were RCTs, while 28 were pre–post studies, 18 quasi-experimental, with the rest being cohort, cross-sectional, time-series, case–control, or descriptive designs . This inclusive approach is justified because many interventions to improve geriatric care in EDs have been evaluated in real-world settings where RCTs may be unfeasible; by including observational and quality-improvement studies, the review captures valuable evidence that would have been missed if it only considered trials. The authors did not explicitly explain this choice in the text, but the diversity of included designs reflects a comprehensive evidence-gathering strategy.
• Quality Assessment of Included Studies: Importantly, the reviewers appraised the methodological quality (risk of bias) of all included studies. They used the Joanna Briggs Institute (JBI) critical appraisal tools appropriate to each study design, applied independently by pairs of reviewers . Any discrepancies in quality ratings were resolved by consensus . By doing this, the review accounted for the internal validity of the evidence. The results of these quality assessments are documented (the article references a Supplement 3 containing the detailed risk-of-bias evaluations) . In the narrative, the authors highlight common quality issues found – for example, some RCTs lacked allocation concealment, and many non-randomized studies had baseline differences between comparison groups – indicating that they did consider how trustworthy each study was . This thorough critical appraisal of included studies is a strong point, as it informs readers about the confidence we can place in each study’s findings.
• Data Synthesis: Given the heterogeneity of interventions and outcomes across studies, the review did notperform a meta-analysis (no pooling of results statistically). Instead, the authors used a narrative synthesisapproach, specifically described as a hermeneutic method . This involved iterative discussion and interpretation of the interventions and findings, and grouping the studies into thematic categories . They categorized interventions into four major groups: (1) comprehensive assessment and multifaceted care, (2) targeted care (addressing specific issues like falls risk or functional decline), (3) medication safety initiatives, and (4) trauma care protocols . By organizing the evidence in this way, the authors could synthesize results within each category more meaningfully. This qualitative synthesis is appropriate for the data because the studies were too diverse in design and outcomes to combine statistically. The hermeneutic approach allowed the reviewers to interpret patterns and themes (for instance, identifying that many interventions aim to reduce admissions or improve flow, while relatively few addressed patient experience). Overall, the chosen synthesis method matches the nature of the evidence.
• Results Presentation: The review’s findings are presented in a clear and accessible manner. The authors include summary tables for each intervention category, listing each study with its author/year/country, the outcome measures evaluated, results for intervention vs. control (if applicable), p-values, and even an assigned “level of evidence” rating for that study . For example, the tables indicate whether a study is Level II evidence (an RCT) or Level III (observational) and whether the intervention had a positive effect (+), no effect (ne), or negative effect, on each outcome . This detailed tabulation of results with statistical outcomes and evidence grading is a strength – it allows clinicians and readers to quickly see the magnitude and direction of effects across studies and the quality of evidence behind them. In addition, the article references Supplement 2 for detailed characteristics of each included study and provides a PRISMA flow diagram (Figure 1) showing how studies were filtered. All these reporting elements enhance transparency and reproducibility. One minor point is that, while the PRISMA flow diagram summarizes numbers of excluded studies for certain reasons, the review does not list each excluded study with a reason individually (common in PRISMA-based reports, but not required in the main text). Overall, the result presentation is thorough and reader-friendly.
• Consideration of Bias in Findings: The review authors demonstrate appropriate caution in interpreting their findings, given the limitations of the included studies. They explicitly note that many included studies have potential biases and this affects what can be concluded. For instance, among the RCTs, 4 out of 9 did not use allocation concealment, and blinding was often not possible; among the non-randomized studies, just over half had issues with comparable groups (selection bias) . These weaknesses mean the results of some interventions could be due to confounding or other biases rather than the intervention itself. The authors state that, consequently, it was “not possible to identify the key elements of interventions and features of ED environments that influence outcomes” across all studies . In other words, because the evidence was heterogeneous and sometimes of moderate quality, they refrain from over-generalizing. This honesty about the risk of bias and uncertainty in the evidence indicates a responsible interpretation. The review does not perform a formal GRADE assessment of the overall evidence strength per outcome, but the narrative commentary serves a similar purpose by qualitatively conveying confidence levels (or lack thereof). Publication bias (the tendency for studies with positive results to be published) was not formally assessed via funnel plots since no meta-analysis was done, but given the inclusion of many study types and the broad search, the risk of major publication bias affecting conclusions is low.
• Conflict of Interest and Funding: The review is transparent about its own funding and potential biases. It received funding from an Australian government Medical Research Future Fund grant and this is clearly disclosed . The authors also declare that they have no competing interests that could have influenced the review’s conduct or interpretation . This transparency is important for trustworthiness. There is no indication that the funding source had any role in the review beyond support, so the risk of author-level bias is minimal. Additionally, having a large team of authors (many of whom are experts in health services research) and using consensus processes likely balanced any individual biases.

Overall, according to this appraisal, the systematic review by Churruca et al. (2024) meets most criteria of a high-quality review. It has a well-defined question, comprehensive search, rigorous methods for study selection and quality appraisal, and transparent reporting. Minor limitations in methodology (like language restriction) are acknowledged by the authors and do not significantly undermine the reliability of the review itself. The primary limitations stem from the available studies’ quality rather than the review process. These strengths and weaknesses are summarized in the next section.

Strengths and Limitations of the Review

Strengths

• Well-defined and relevant scope: The review addresses a significant clinical issue – improving emergency care for older adults – with clearly defined parameters. It encompassed multiple outcome domains including patient health outcomes, patient experience, staff experience, and system performance, reflecting a comprehensive perspective on “quality of care” . By incorporating the viewpoints of patients and providers as well as system metrics, the review aligns with modern healthcare goals and ensures that its findings are meaningful for holistic ED improvements.
• Robust methodology: This review was conducted with rigorous systematic review methods. The authors had an a priori protocol (registered in PROSPERO) and adhered to PRISMA guidelines for transparent reporting . A broad, multi-database search strategy was employed, and study selection and data extraction were done in duplicate by independent reviewers , with mechanisms to resolve disagreements. These practices greatly enhance the credibility of the review by minimizing bias at each stage (identification, selection, and data collection).
• Extensive evidence base: A large number of studies (76 in total) from diverse healthcare systems were included . This breadth is a strength because it captures a wide array of interventions and contexts – from the US and Europe to Australia – providing a panoramic view of how ED care for seniors can be improved. The inclusion of 12 Australian studies is particularly relevant for local applicability. The extensive evidence base increases the external validity of the review’s conclusions, as they are drawn from varied settings rather than a single country or study type.
• Systematic quality appraisal: The review did not take included studies’ findings at face value – each study was critically appraised for quality using standardized JBI tools. The authors openly discuss the common methodological limitations found (for example, noting when studies lacked blinding or used non-randomized designs) . This adds confidence that the review’s authors weighed the strength of evidence appropriately. By highlighting these issues, the review guides readers on how much stock to put in certain results. The explicit consideration of risk of bias is a major quality indicator for a systematic review.
• Transparent and detailed reporting: The review’s results are presented with a high level of detail and clarity. Comprehensive tables (in the article and supplements) outline each intervention’s outcomes, effect sizes, and statistical significance, along with an assigned level-of-evidence for each study . Such tables make it easy for clinicians or policymakers to identify which interventions showed benefits and the robustness of those findings. Furthermore, the authors provided supplementary materials (e.g. the full search strategy and a detailed description of each study in Supplement 2 , and risk of bias data in Supplement 3), which is a hallmark of transparency. The review also fully discloses its funding source and declares no conflicts of interest , indicating that the work was likely conducted and reported without undue bias. All these factors strengthen the trustworthiness of the review.

Limitations

• Predominantly lower-level evidence: The overall evidence included in the review tends to be of limited quality. Only 9 of the 76 included studies were randomized trials, while the majority were observational or quasi-experimental designs . Many interventions were evaluated without rigorous controls or blinding. The authors note, for example, that in the RCTs included, allocation was not concealed in nearly half, and most studies (including non-RCTs) did not or could not blind participants or personnel . In over half of the non-randomized studies, the comparison groups may not have been truly equivalent at baseline . These weaknesses introduce potential biases (selection bias, placebo effects, etc.) that diminish the confidence in drawing cause-and-effect conclusions. As a result, the strength of evidence for many interventions is moderate or low.
• Heterogeneity of interventions and contexts: The interventions covered in this review were highly heterogeneous, ranging from comprehensive geriatric assessment teams to falls prevention protocols to medication review processes. They were implemented in varied ED environments across different countries. This variability made direct comparisons difficult and meant a meta-analysis was not feasible. Moreover, contextual factors that might influence an intervention’s success (such as hospital resources, staff training, or baseline ED processes) were not consistently reported in the studies . The review itself emphasizes that the complex interplay of an intervention with its specific ED setting often went undescribed, which is a limitation. Because of this heterogeneity and lack of contextual detail, it is hard to generalize exactly which components of these interventions are universally effective. The review could not distill a “one-size-fits-all” solution, since what worked in one hospital’s ED might not in another’s due to unreported contextual differences.
• Outcome reporting gaps: There were gaps in the outcomes reported by the included studies, especially regarding the experience of patients and staff. Only a small fraction of studies measured patient experience (about 10%) or staff experience (~6%) as outcomes . This is an important limitation because improvements in care processes do not automatically translate to better patient or staff satisfaction, yet those domains are critical for a complete assessment of care quality. The review had aimed to examine all four domains of the quadruple aim, but the paucity of data on two of those domains (experience measures) means conclusions in those areas are weak. In essence, the evidence base is skewed more toward “hard” outcomes like admissions, length of stay, or clinical metrics, and less toward “softer” yet vital outcomes like patient-centered experience. The authors highlight this as a gap, suggesting future studies should incorporate patient and staff experience more consistently.
• Language and publication bias potential: The review’s restriction to English-language, peer-reviewed studies could introduce bias. By excluding non-English publications, the review may have missed relevant research or successful interventions reported in other languages or regions (for example, studies from non-English-speaking countries dealing with similar ED challenges) . Similarly, excluding gray literature (such as quality improvement reports, conference proceedings, or thesis works) means interventions implemented by hospitals that were never published in journals are not captured. It is possible that some negative or inconclusive intervention studies remain unpublished, or successful pilot projects exist only in internal reports. These factors could bias the overall picture (for instance, if only positive studies tend to be published in English). The authors acknowledge the English-only limitation as one affecting external validity . While this is a common practical choice in reviews, it does limit the breadth of evidence and is a caveat to consider when applying the results globally.
• Inability to identify definitive best practices: Because of the above limitations – variability in studies and moderate risk of bias – the review stops short of naming any single intervention strategy as clearly superior. The authors could not isolate specific “key elements” of interventions that consistently led to improved outcomes . In other words, the review finds multiple promising strategies but cannot conclusively pinpoint which components are most critical for success. This is an inherent limitation in the evidence, not a flaw of the review per se, but it affects how useful the findings are for immediate policy decisions. Clinicians and decision-makers are left with a menu of options that have shown some benefit in certain contexts, rather than a guaranteed blueprint for success. The guidance is therefore somewhat broad and requires local adaptation (as discussed below). The uncertainty arising from the evidence base means the review’s conclusions come with the caution that results may vary depending on context and implementation.

Summary of Evidence Strength and Risk of Bias

In summary, the systematic review by Churruca et al. (2024) is well-conducted and provides a valuable aggregation of what is known about improving care for older adults in EDs. The strength of evidence for the interventions identified, however, is moderate at best due to limitations in the primary studies. The review itself is trustworthy (thanks to strong methods), but it is constrained by the quality of available data. Most included studies were not randomized trials, and many had design weaknesses that introduce risk of bias. As the authors point out, the heterogeneity and methodological issues meant they “were not able to identify the key elements” that consistently drive positive outcomes across all settings . In practical terms, this means the evidence is suggestive rather than definitive. There is a moderate risk of bias influencing the pooled findings: some interventions that appeared to help (for example, reducing admissions or ED length of stay) might have benefited from favorable context or uncontrolled factors, while others might have shown no effect due to study limitations rather than true ineffectiveness. The review’s conclusions are appropriately cautious and tempered by these considerations – it does not claim dramatic certainty but rather highlights patterns and misalignments. For instance, it emphasizes the misalignment between comprehensive geriatric care and traditional ED performance metrics, and it notes the gap in measuring patient/staff experiences. These insights are drawn from the data despite its imperfections. Overall, the evidence compiled suggests a direction for improving geriatric ED care (comprehensive, multifaceted approaches seem beneficial), but because of the risk of bias and inconsistent reporting, stakeholders should interpret the findings with caution. Further high-quality research (more rigorous trials or well-designed comparative studies in ED settings) would be needed to strengthen the confidence in any specific intervention. In effect, the review provides a solid foundation and identifies important themes, but acknowledges that the absolute certainty of benefit is limited by the underlying studies’ weaknesses.

Applicability of Findings to ED Practice in Australia and New Zealand

The findings of this systematic review are highly relevant to clinical practice in emergency departments in Australia and New Zealand, given similar demographic trends and healthcare system challenges in these countries. Both Australia and NZ are experiencing aging populations and increasing ED presentations by older patients. In Australia, for example, people aged 65 and over comprise about 16% of the population but account for 21% of ED presentations , and over half of these older ED patients end up being admitted to hospital, a rate much higher than that of younger patients . New Zealand faces comparable statistics with an aging demographic and pressure on ED services. This means the central issue addressed by the review – how to improve care for older adults in ED while maintaining ED performance – is directly pertinent in the ANZ context.

Many of the intervention strategies identified in the review can be applied or are already being tried in Australian and New Zealand EDs. In fact, the review included 12 studies from Australia , indicating that several of these approaches (such as geriatric assessment teams in ED, falls risk protocols, “frailty pathways,” etc.) have been tested in local hospitals. This provides a degree of local evidence. For instance, some Australian hospitals have implemented comprehensive geriatric emergency department intervention programs (often involving geriatricians or aged care nurses embedded in the ED) and reported improvements in patient flow and outcomes, which aligns with the review’s category of “comprehensive assessment and multifaceted care.” Likewise, medication safety interventions like pharmacist-led medication reviews in the ED, and targeted care initiatives (e.g. delirium prevention protocols) are strategies that ANZ EDs have been exploring, consistent with the review’s findings. The fact that these were included and showed positive trends in the review suggests they are feasible and potentially beneficial in our healthcare settings.

One key insight from the review is the misalignment between the needs of older patients and traditional ED performance metrics . In Australia and New Zealand, ED performance has historically been measured by time-based targets (such as the 4-hour National Emergency Access Target in Australia, or the shorter-stay target in NZ) and other throughput metrics. The review highlights that interventions focusing on thorough, geriatric-friendly care (which may take more time initially) often do not translate into immediate improvements in these metrics and can even appear at odds with the pressure to move patients through quickly . For example, a comprehensive geriatric assessment might lengthen an elder patient’s time in the ED but yield better outcomes post-discharge. This finding is very applicable to ANZ ED management: it suggests that health administrators should be cautious about using only speed/throughput as measures of success for older patient care. We may need to adjust local KPIs (key performance indicators) or create new ones that capture the value gained by these interventions (such as reduced readmissions, improved functional outcomes, or patient satisfaction), rather than solely focusing on length of stay. In practice, ED leaders in Australia and NZ could use this evidence to advocate for more nuanced performance metrics or flexible targets for older patients, ensuring that quality care isn’t unintentionally discouraged by the metrics.

Another important aspect for applicability is the review’s emphasis on including patient and staff experience as outcomes and in designing interventions. While few studies measured these, the authors conclude that future strategies should better incorporate patient and staff input at the design stage to ensure interventions are high-impact and workable . This aligns well with the current push in Australia and NZ healthcare toward co-design and patient-centered care. Hospitals in our region are increasingly involving consumers and frontline clinicians when developing new models of care. The review’s recommendation supports this approach: for any ED improvement initiative targeting older adults in ANZ, engaging with the patients (and their families) and ED staff during planning can improve buy-in and effectiveness. It’s a reminder that solutions need to be tailored to the local context and that those who deliver and receive the care can provide invaluable insights into what will actually succeed. For example, if an ED in New Zealand were to set up a new “geriatric fast-track” or lounge, involving geriatric patients’ feedback on comfort, and nurses’ feedback on workflow, would likely echo the review’s guidance for inclusive design .

From a policy and system standpoint, the review supports the case for investments in specialized geriatric care processes within EDs. For Australia and NZ, which have publicly funded healthcare systems, the evidence compiled can inform guidelines and funding decisions. If, say, a Local Health District or District Health Board is considering implementing an ED-based allied health team for frail seniors, the review provides an inventory of what has been tried elsewhere and what outcomes were observed. Decision-makers can note that interventions like comprehensive geriatric assessment units, or risk screening followed by targeted care plans, have been associated with reductions in hospital admissions or ED re-attendances in some studies (including Australian ones). They can also see that certain areas are under-addressed (like patient experience), and thus ensure new programs include those components (for example, adding a focus on communication, comfort, and reducing anxiety for older patients, which were factors highlighted in some interventions).

It’s also worth noting that while New Zealand was not explicitly represented among the 76 studies in the review, the similarity in emergency care structure and patient profiles between NZ and Australia means the findings are largely transferable. Both countries have multidisciplinary ED teams and face issues like access block and crowding, which affect older patients significantly. Thus, strategies that improved “system performance” in the review (such as protocols to reduce unnecessary hospital admissions or fast-track specific cases) could be trialed in NZ hospitals with likely similar outcomes. Each local ED would need to adapt the specifics – for instance, a falls prevention program might use different screening tools or referral options depending on local services – but the core idea remains applicable.

Finally, applying these findings requires acknowledging the limitations of the evidence. Clinicians and managers in Australia/NZ EDs should view the review’s recommendations as guiding principles rather than guaranteed solutions. Because the evidence base has some uncertainty, any new intervention adopted from these strategies should be coupled with local evaluation. In practice, an ED might implement a new geriatric model of care and monitor its own outcomes (e.g. perform a local quality study) to verify that it indeed improves patient outcomes without adverse effects on flow. The review highlights promising interventions and common themes – such as the value of comprehensive geriatric assessment, importance of care coordination and follow-up, ensuring medication safety, and tailoring trauma care to older physiology – all of which are applicable to our EDs. The key is to integrate these in a way that fits the local patient population and hospital workflows.

In conclusion, the systematic review by Churruca et al. offers a valuable compilation of strategies that could improve the care of older adults in emergency departments. For Australia and New Zealand, where aging populations are putting pressure on ED services, these findings are highly pertinent. The review’s insights encourage EDs to adopt a more elder-friendly approach (through dedicated teams or protocols), but also caution that success requires alignment with system goals and careful implementation. Hospital and ED leaders in ANZ can use this evidence to justify innovations in geriatric emergency care, while researchers can build on the identified gaps (such as measuring patient experience, and conducting more rigorous trials) to strengthen the evidence in our context. Ultimately, applying these strategies – with appropriate adaptations – could lead to better health outcomes and experiences for older patients in our emergency departments, which is a priority for health systems facing the challenges of an aging society.

Sources:

• Testa L. et al. (2024). Strategies to improve care for older adults who present to the emergency department: a systematic review. BMC Health Serv Res 24:178 .
• Testa L. et al. (2024). Ibid. – Methods and Results . (See text for detailed context from these references.)