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Physicians with postgraduate training in caring for older adults–geriatricians, geriatric psychiatrists, and Care of the Elderly family physicians (FM-COE)–have expertise in managing complex care needs. Deficits in the geriatric-focused physician workforce coupled with the aging demographic necessitate an increase in training and clinical positions. Descriptive analyses of data from established matching systems have not occurred to understand the preferences and outcomes of applicants to geriatric-focused postgraduate training. This study describes applicant and match trends for geriatric-focused postgraduate training in Canada. In this retrospective cohort study, data from the Canadian Resident Matching Service and FM-COE program directors were analysed to examine program quotas, applicants’ preferences, and match outcomes by medical school and over time. Based on their first-choice specialty ranking, applicants to geriatric medicine and FM-COE signalled a preference to pursue these programs and tended to match successfully. The proportion of unfilled training positions has increased in recent years, and the number of applicants has not increased consistently over time. There is a disparity between applicants to geriatric-focused training and the health human resources to meet population-level needs. Garnering interest among medical trainees is essential to address access and equity gaps.
The 2016 Canadian Triage and Acuity Scale (CTAS) updates introduced frailty screening within triage to more accurately code frail patients who may deteriorate waiting for care. The relationship between triage acuity and frailty is not well understood, but may help inform which supplemental geriatric assessments are beneficial to support care in the emergency department (ED). Our objectives were to investigate the relationship between triage acuity and frailty, and to compare their associations with a series of patient outcomes.
We conducted a secondary analysis of the Canadian cohort from a multinational prospective study. Data were collected on ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Triage acuity was assigned using the CTAS, whereas frailty was measured using an ED frailty index. Spearman rank and binary logistic regression were used to examine associations.
A total of 2,153 ED patients were analyzed. No association was found between the CTAS and ED frailty index scores assigned to patients (r = .001; p = 0.99). The ED frailty index was associated with hospital admission (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.4–1.6), hospital length of stay (OR = 1.4; 95% CI = 1.2–1.6), future hospitalization (OR = 1.1; 95% CI = 1.05–1.2), and ED recidivism (OR = 1.1; 95% CI = 1.04–1.2). The CTAS was associated with hospital admission (e.g., CTAS 2 v. 5; OR = 6; 95% CI = 3.3–11.4).
Our findings demonstrate that frailty and triage acuity are independent but complementary measures. EDs may benefit from comprehensive frailty screening post-triage, as frailty and its associated geriatric syndromes drive outcomes separate from traditional measures of acuity.
Patient assessment is a fundamental feature of community paramedicine, but the absence of a recognized standard for assessment practices contributes to uncertainty about what drives care planning and treatment decisions. Our objective was to summarize the content of assessment instruments and describe the state of current practice in community paramedicine home visit programs.
We performed an environmental scan of all community paramedicine programs in Ontario, Canada, and used content analysis to describe current assessment practices in home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy.
A total of 43 of 52 paramedic services in Ontario, Canada, participated in the environmental scan with 24 being eligible for further investigation through content analysis of intake assessment forms. Among the 24 services, 16 met inclusion criteria for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Most assessments included some content from each of the domains outlined in the ICF. At the subdomain level, only assessment of impairments of the functions of the cardiovascular, hematological, immunological, and respiratory systems appeared in all assessments.
Although community paramedicine home visit programs may differ in design and aim, all complete multi-domain assessments as part of patient intake. If community paramedicine home visit programs share similar characteristics but assess patients differently, it is difficult to expect that the resulting referrals, care planning, treatments, or interventions will be similar.
The aim of this study is to identify the types of community paramedicine programs and the training for each.
A systematic review of MEDLINE, Embase, grey literature, and bibliographies followed a search strategy using common community paramedicine terms. All studies published in English up to January 22, 2018, were captured. Screening and extraction were completed in duplicate by two independent reviewers. The Mixed Methods Appraisal Tool (MMAT) was used to assess studies’ methodological quality (full methodology on PROSPERO: CRD42017051774).
From 3,004 papers, there were 64 papers identified (58 unique community paramedicine programs). Of the papers with an appraisable study design (40.6%), the median MMAT score was 3 of 4 criteria met, suggesting moderate quality. Programs most often served frequent 911 callers (48.3%) and individuals at risk for emergency department admission, readmission, or hospitalization (41.4%); and 70.7% of programs were preventive home visits. Common services provided were home assessment (29.5%), medication management (39.7%), and referral and/or transport to community services (37.9%); and 77.6% of programs involved interprofessional collaboration. Community paramedicine training was described by 57% of programs and expanded upon traditional paramedicine training and emphasized technical skills. Study heterogeneity prevented meta-analysis.
Community paramedicine programs and training were diverse and allowed community paramedics to address a spectrum of population health and social needs. Training was poorly described. Enabling more programs to assess and report on program and training outcomes would support community paramedicine growth and the development of formalized training or education frameworks.
Geriatric patients represent a large and complex subgroup seen in emergency departments (EDs). Competencies in geriatric emergency medicine (EM) training have been established. Our objectives were to examine Canadian postgraduate year (PGY)-5 EM residents’ comfort with the geriatric EM competency domains, assess whether Canadian EM residents become more comfortable through residency, and determine whether geriatric educational exposures are correlated with resident comfort with geriatric EM.
A national, cross-sectional study of PGY-1 and PGY-5 Royal College EM residents was conducted to determine their comfort in geriatric EM clinical competency domains. Residents reported their level of comfort in satisfying each competency domain using a seven-point Likert scale. Residents were also asked about the location of their medical education as well as the type and number of different geriatric exposures that they had received to date.
Of the 141 eligible residents from across Canada, 77% (109) consented to participate. None of the PGY-1 EM residents and 34% (14) of PGY-5 EM residents reported that they were comfortable with all eight geriatric EM competency domains. PGY-5 EM residents were significantly more comfortable than PGY-1 EM residents. Residents reported a highly variable range of geriatric educational exposures obtained during training. No relationship was found between resident-reported comfort and the nature or number of geriatric exposures that they had received.
Current Royal College EM residency training in Canada may not be adequately preparing graduates to be comfortable with defined competencies for the care of older ED patients.
The heart failure epidemic predominantly affects older people, particularly those with concurrent co-morbid conditions and geriatric syndromes. Mortality and heath service utilization associated with heart failure are significant, and extend beyond the costs associated with acute care utilization. Over time, older people with heart failure experience a journey characterized by gradual functional decline, accelerated by unpredictable disease exacerbations, requiring greater support to remain in the community, and often ultimately leading to institutionalization. In this narrative review, we posit that the rate of functional decline and associated health care resource utilization can be attenuated by optimizing the management of heart failure and associated co-morbidities. However, to realize this objective, the manner in which care is delivered to frail older people with heart failure must be restructured, from the bedside to the level of the health care system, in order to optimally anticipate, diagnose and manage co-morbidities.