Life In The Slower Lane

Here is the structured PICO analysis for the fifteenth article you uploaded:

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Full Title (verbatim and exact):

“Factors associated with increased Emergency Department transfer in older long-term care residents: a systematic review”

Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S

The Lancet Healthy Longevity (2022); 3:e437–e447

DOI: https://doi.org/10.1016/S2666-7568(22)00113-1

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Type of Article:

Systematic review of observational studies with quantitative modelling

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PICO Analysis:

Population:

• Older long-term care residents (aged ≥65 years) living in care homes (residential or nursing facilities)
• Studies included were conducted primarily in North America, Hong Kong/Taiwan, and Europe
• Excluded were residents in specialist settings (e.g. dementia-only or palliative care cohorts) 

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Intervention:

• Resident-level and care home-level factors potentially associated with increased Emergency Department (ED) transfers
• This review assessed exposure to specific characteristics (e.g., demographics, comorbidities, care home quality) as predictive factors

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Comparator:

• Residents or facilities without the exposure of interest, e.g., comparison of those with vs. without dementia, different age groups, staffing levels, etc.

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Outcome:

1. Person-centred outcomes (ED transfer as proxy):

• Not measured directly in terms of quality of life, but ED transfer was used as a proxy for outcomes that may indicate potential overuse, underuse, or appropriateness of hospital care

2. Process outcomes:

The review identified several predictors of ED transfer, grouped into seven domains:

• Demographics:
  • Male sex consistently associated with higher ED transfer (adjusted OR range: 1.05–1.27)
  • Age findings were mixed—both increasing and decreasing age associated with risk in different models
• Comorbidities:
  • Congestive cardiac failure, COPD, renal failure, and polypharmacy all consistently associated with higher ED transfer
  • Mixed findings on dementia—severe dementia linked to fewer transfers, mild/moderate possibly more
• Frailty and function:
  • Worse ADL performance and frailty consistently associated with higher ED transfers
• Medication use:
  • Psychotropic medications, new prescriptions, and polypharmacy linked to increased ED transfers
• Indwelling devices:
  • Use of urinary catheters and feeding tubes significantly associated with increased transfers (OR up to 2.1)
• Advance directives:
  • Do-not-resuscitate orders associated with reduced ED transfer; Do-not-hospitalise orders less consistently protective
• Care home organisational factors:
  • Higher quality ratings, specialist dementia units, rural location, and non-profit/public ownershipassociated with reduced transfers
  • For-profit status and larger facility size inconsistently associated 

3. Health system outcomes:

• Identifies key modifiable factors (e.g. medication practices, staffing, facility characteristics) that could be targeted by policies or interventions to reduce potentially avoidable transfers
• Variation in ED transfer rates across facilities (up to 9-fold) suggests substantial system-level opportunity for optimisation
• Limitations in statistical methodology (e.g., few studies used multilevel models to adjust for clustering) and lack of UK-based data limit generalisability 

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Summary Conclusion:

This high-quality systematic review synthesises evidence on factors associated with Emergency Department transfers among long-term care residents. It identifies modifiable and non-modifiable predictors, highlighting key targets for quality improvement initiatives in aged care, such as polypharmacy, device use, and facility-level variables like staffing and quality ratings. The review supports the potential for risk-adjusted modelling of ED transfers as a care home quality indicator and emphasises the need for consistent methodologies and context-specific policy interventions.

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