158 Chapter 7 the educational needs of emergency physicians. A qualitative study design with interviews with a few emergency physicians locally would not have yielded data representing all of the Netherlands. The response rate of the emergency physicians (37.8%) in our study aided in alleviating the selection bias that is inherent to study designs based on survey data. Variability in response rates in survey studies with medical specialists is common (11). We also minimized the effect of the nonresponse bias by inviting as many representative physicians as possible, providing them sufficient time to respond, and reminding them of the study when appropriate. In this study, we not only surveyed emergency physicians but also included managers of all EDs in the Netherlands. We believe that ED managers might play a significant role in facilitating local geriatric emergency medicine education for emergency physicians. Until now, no data were available showing to what extent ED managers actively support geriatric education for emergency physicians. The group of policy makers should not be forgotten in these studies because the implementation of protocols and local education is also dependent on the support of management staff. In our study, managers reported that although sufficient expertise for geriatric education was available in their hospital, limited time and limited finances were available to organize education for emergency physicians, and it could therefore not be prioritized. Second, we evaluated a geriatric education program for emergency physicians. Mixed methods studies generate a large body of data that may be challenging to analyse and interpret. This could be minimized by presenting the quantitative and qualitative data separately. While this may seem like an easy solution, we chose not to do this because the limitation of this technique is that the advantage of combining qualitative and quantitative data in the same study diminishes for the reader since they only see these aspects separated. To minimize any bias that may result from the mixed methods approach, we paid explicit attention to transparency in our study design and ensured that our methods were specifically linked to our research question (12). Third, in our studies, we defined older adults as patients aged 70 years or older, which had implications for the comparability of the published data. Despite the increasing academic attention on older adults presenting at the ED, there is no uniform definition of “older adult” in the literature. For example, we noticed in our systematic review in which we reviewed 16 studies that there was large variation in the studied populations by age: ten studies included patients aged ≥ 65 years, three included patients ≥ 75 years, two included patients aged ≥ 70 years, and one included patients aged ≥ 60 years. We made sure to provide a clear definition of our study population in each of our studies, but the comparability of studies for this vulnerable and ever-growing population would greatly benefit from more uniform definitions when studies are conducted.
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