A Shared Decision-Making Tool to Support Emergency Department Dispositions for Veterans with Dementia
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It is currently estimated that 10% of the Veteran population aged ≥65 years has Alzheimer’s disease or Alz- heimer’s disease related dementias (AD/ADRD), and this number is expected to increase by 22% in the next decade. The Emergency Department (ED) is an essential care setting for these persons living with dementia (PLWDs), with 40% of community-dwelling PLWDs making at least one ED visit per year. One of the most im- pactful and costly elements of ED care is the decision to admit a patient to the hospital or discharge them home- the “disposition” decision. ED providers must balance the risks of unnecessary admissions, such as delirium and functional decline, against the risks of discharge, which may result in return ED visits and hospitalizations. The disposition decision is difficult when the need for hospitalization for further testing or monitoring is unclear. It can also be especially challenging with PLWDs, as they can have difficulties in providing accurate histories to guide ED testing and diagnosis. There is significant variation in ED disposition practices, driven by factors including patient sociodemographics and comorbidities, as well as physician risk tolerance. ED providers lack best prac- tices to incorporate PLWD and caregiver values and preferences in the disposition decision when there is no serious illness that clearly requires admission. Shared decision making (SDM) tools can facilitate complex con- versations between patients, caregivers, and ED providers, to ensure that patients and caregivers are meaning- fully involved in decisions about their care. The research proposed in this application is designed to develop a shared decision making tool to support ED dispositions that are aligned with PLWD and caregiver goals, and thereby improve outcomes for Veteran PLWDs and their caregivers. With the support of her mentorship team, this proposal is also intended to support the continued career devel- opment of Dr. Justine Seidenfeld, an extremely promising emergency medicine physician-scientist, within the field of emergency care health services research. During this period of support, she will pursue didactic instruc- tion and further training to 1) advance her skills in methods for conducting research with PLWDs and their caregivers, 2) learn best practices to design and implement interventions aligned with end-user needs, and 3) develop skills for development and testing of SDM tools. The expected outcome of this proposal is to construct and pilot test a SDM tool to support high-quality ED dispositions for PLWDs. Along with mentored training, this will position her to submit a competitive Investigator Initiated Research (IIR) application to test its effectiveness in a fully powered trial. Her long-term career objective is to become an independent health services researcher, skilled in using diverse methods to promote high-quality ED care for Veterans with dementia. This study employs a sequential design based on the 3-step decision aid development process created by the International Patient Decision Aid Standards (IPDAS) collaboration. Aims 1 and 2 will address the first “under- stand user” step through quantitative and qualitative methods. Aim 1 will calculate home time (i.e., days alive and out of acute and post-acute settings) after an ED visit for a cohort of Veterans with dementia, and identify Veteran, ED facility, and visit type characteristics that are associated with variation in home time to suggest groups that may benefit from a customized SDM tool. Aim 2 will use qualitative interviews with Veteran PLWDs, their caregivers, and ED providers after an ED visit to assess their unmet needs, values, and preferences when making a disposition decision. To fulfill the “development/refinement” and “assessment” steps of the IPDAS de- velopment process, Aim 3a will create and iteratively refine a prototype SDM tool with feedback from a multidis- ciplinary collaborator panel, and Aim 3b will then use a iterative cohort pilot study design to assess the feasibility and acceptability among PLWDs, caregivers, and ED providers.
