Development and Validation of a Patient-Reported Experience Measure for Older Adults Attending the Emergency Department: The PREM-ED 65 Study

Abstract

Emergency Department (ED) care traditionally focuses on resolving single-organ pathology, emphasising rapid patient flow. As such, ED care may fall short of addressing the holistic needs of older adults, where atypical and complex presentations exacerbated by frailty, comorbidity, polypharmacy, and sensory deficits are much more prevalent than in the general population. Older adults are particularly vulnerable to the effects of ED crowding and prolonged length of ED stay and suffer increased in-hospital mortality as a result.

Patient experience is a central determinant of quality of care and is positively associated with improved outcomes for acute conditions, including pneumonia, asthma, and acute coronary syndrome. Patient Reported Experience Measures (PREMs) assess patients' self-reported care experiences, identifying vulnerabilities in care from their perspective and providing impetus for patient-centred quality improvement. Other applications of PREMs may include individual and systems-level performance monitoring and comparison or benchmarking of services.

This thesis presents a mixed-methods methods study conducted to develop and validate a new PREM for adults over 65 attending the ED (PREM-ED 65). Justification for the study is provided through a critical discussion of the purpose of the modern ED, the concept of healthcare quality, and a critique of current ED performance indicators. A broad conceptual exploration of older adults’ experiences of ED care forms the basis for developing the PREM-ED 65 instrument. Firstly, a qualitative systematic review and meta-synthesis summarised findings from 22 studies, and thematic synthesis derived a novel conceptual framework for patient needs in the ED. A scoping literature review then identified and evaluated existing patient-reported measures applicable to the ED, highlighting the absence of a suitably validated ED PREM for older adults.

The conceptual framework was further expanded by undertaking in-situ interviews with older adults in the ED (n=24) and focus groups with ED care providers (n=37). Framework analysis and methodological triangulation of findings resulted in a comprehensive list of draft PREM items.

Draft items were assessed by multiple stakeholders (n=29) using a nominal groups technique, and final refinement was performed during cognitive interviews (n=7), resulting in an 82-item draft instrument.

The draft instrument was administered to patients across 13 different NHS Trusts in England. Analysis of the responses (n=511) consisted of hierarchical item reduction, exploratory factor analysis, and assessment of test-retest reliability. As a result, a finalised, 25-item version of PREM-ED 65 is proposed that provides reliable measurement of relational care, the ED environment, information provision, and pain assessment. Future work should include validation for patient cohorts admitted to the hospital, cross-cultural adaptation, validation to confirm measurement properties in underrepresented groups and the development of additional scales for older adults living with disabilities or sensory impairment.