Faculty Bibliography

Background: We recently implemented the Age-Friendly Health System's 4Ms (What Matters, Medication, Mentation, and Mobility) framework in New York City Health + Hospitals/Bellevue Hospital Center's Geriatrics clinic to improve care of older adults.
Method(s): We examined the impact of 4Ms assessment on patient care and changes in care processes through specific interventions triggered after assessment. We conducted chart reviews of patient visits during March 2021, the first month of 4Ms implementation and identified interventions made during these visits. To assess "What Matters" providers asked "What Matters the most to you;" potentially inappropriate Medications (PIM) were identified using the Beers list; Mentation was evaluated using the Mini-Cog; and Mobility was determined using timed up and go (TUG) test. We used descriptive statistics to characterize findings.
Result(s): Among the 121 patients who had 4Ms assessment in March 2021, 85% (n=103) were asked "What Matters;" providers reviewed Medications for almost all (n=118; 98%) and conducted a Mini-Cog for 64% (n=78). Most not cognitively assessed were either previously screened (n=11; 9%) or had dementia (n=12; 10%). Providers used the TUG test for 87% (n=105). What Mattered to patients most commonly was "getting better" (n=24; 23%). There were 39 (33%) patients with potentially inappropriate Medications (including proton pump inhibitors, gabapentinoids, and NSAIDS) of which 10 (26%) Medications were either discontinued or reduced. Other interventions included further cognitive evaluation (n=2) and home care referrals (n=2) among 14 (18%) with an abnormal Mini- Cog. Among the 51 (42%) patients with an abnormal TUG, providers intervened for 19 (37%) with devices, referrals or home services.
Conclusion(s): The adoption of 4Ms assessment during routine visits identified issues with Medications, Mentation and Mobility, triggering several interventions for common geriatric conditions. 4Ms assessment is a helpful strategy to organize geriatric care, routinely assess patients for common geriatric syndromes, and improve care. Future directions include prioritizing interventions integrated with "What Matters" to maintain patient-centered care

Background: Shingrix vaccine is more than 90% effective at preventing herpes zoster and post herpetic neuralgia. The CDC recommends all adults over age 50 should receive two doses. In an urban safety net geriatrics clinic, we identified a significant number of patients who had not received the Shingrix vaccine. We sought to implement an intervention that would increase the rate of vaccination in this patient population.
Method(s): Using the Epic medical records, we reviewed 1,562 patients who visited the Geriatric clinic between 9/1/2020 and 8/31/2021, and identified patients (>65 years) who had not received Zostavax or Shingrix. Between 10/01/21 - 11/15/21, we implemented an intervention, including chart review and telephone outreach to increase Shingrix vaccination rates. We called a convenience sample of 100 patients lacking either vaccine. We asked patients or caregivers about familiarity with shingles and vaccines to prevent shingles; we provided education about shingles and the vaccine, offered vaccination, facilitated immunization appointments, and documented discussions.
Result(s): We identified 962 patients (62%) who did not have either zoster vaccine. Among patients we attempted to call, 78 (78%) answered the phone and 49/78 (63%) were interested in vaccination. 17/22 (77%) received a message regarding the vaccine; 3/22 had incorrect numbers, and 2/22 were deceased. 32 (41%) had an upcoming PCP appointment. 23/78 (29%) were not interested in the vaccine and declined. 3/78 (4%) were undecided and 3/78 (4%) had already completed 2 vaccine doses.
Conclusion(s): In our brief intervention for patients unimmunized against herpes zoster who received phone calls regarding the importance of the Shingrix vaccine, most agreed to receive the vaccine. We continue to monitor the effectiveness of this program and expect that continued education and close follow-up in the geriatrics clinic will lead to increased Shingrix vaccination in this population. This approach may provide a pathway for similar clinics trying to increase vaccination rates

Background: The American Geriatrics Society (AGS) recommends varying Hemoglobin A1C (HbA1c) goals depending on patients' function, cognition, and life expectancy. Given the increasing emphasis on individualizing diabetes care for older diabetes patients, we aimed to improve HbA1c control rates in an inner-city safety net geriatrics clinic through an interdisciplinary approach including proactive patient contact, newly available clinic resources and reevaluation of optimal glycemic medical therapy.
Method(s): We are conducting a quality improvement project that includes 82 patients ages 65-75 with HbA1Cs >=8 who have a diabetes management visit scheduled within the next 6 weeks. Prior to each patient visit, we order an HbA1c and call each patient advising them to bring his/her medication, food diary, and blood sugar log. At each visit, providers complete a standardized diabetes questionnaire that includes: confirmation that the patient's HbA1c goal is <8% or justification of a higher target depending on poor health status, presence of cognitive impairment, falls, functional impairments, and/or hypoglycemic events; referral to newly available diabetes resources such as a certified diabetes educator, nursing visit, or a nutritionist; and suggested regimen changes to SGLT-2 inhibitors or GLP-1 agonist if metformin is insufficient to meet glycemic targets. In 4 months, we re-measure HbA1C levels, clinic resource utilization and changes in prescription of other oral anti-DM medications (e.g. GLP-1 agonists/ SGLT-2 inhibitors).
Result(s): Follow-up data on the first 40 patients demonstrate an increased number of patients meeting HbA1c <8.0% (16/40; 40%) and that providers are referring patients to interdisciplinary resources. However, no changes to oral medication use has yet been observed.
Conclusion(s): Our data suggest that a proactive interdisciplinary approach to diabetes management can increase the number of patients meeting their HbA1c goals. Expanded usage of multimodal techniques could lead to improvement in patient outcomes

Background: Warfarin is efficacious in reducing thromboembolic risks but its use presents challenges to both patients and physicians including the need for monitoring, diet modification, and attention to drug-related interactions. Novel anticoagulants have circumvented many of these issues. Although prior research includes physician consideration of patients' perspective as important in the choice of anticoagulants, patient perceptions about anticoagulant use is unknown.
Method(s): We sought to identify patient perceptions about anticoagulant use in the Geriatrics Warfarin Clinic in Bellevue Hospital, a well-known, large safety net institution in New York City. We formulated a semi-structured telephone interview guide based on prior literature. Two geriatrics fellows (JK, NT) conducted interviews with role switches between interviewer and scribe every 3 interviews. We reviewed interview notes and identified codes. Both fellows independently analyzed all interviews and codes and categorized codes into themes. Any discrepancies were resolved by consensus discussion.
Result(s): Interviews were 10-15 minutes each. Respondents' mean age was 80.4 years (Standard deviation: 8.1); 7 were women (39%). Eight interviews were in English, five (28%) required a language interpreter and five were by proxy at patient request. Thematic saturation was reached at 18 patient interviews revealing six themes. These were: resignation about current warfarin use (n=12); lack of knowledge of alternative anticoagulation (n=16); perceived need for monitoring and efficacy checks (n=6); concerns about side effect profile (n=7); primary physician's recommendation (n=7) and dietary restrictions (n=4). Preference for warfarin use was driven by ability to know its therapeutic level and many patients expressed hesitance in switching with no monitoring procedure.
Conclusion(s): Patients' use of warfarin was generally well accepted. The primary concern was need for dietary modification. Of those patients that appeared neutral or accepting of alternative anticoagulation, the main discussion points were the drug's efficacy, side effect profile, and their physician's recommendation. This study provides useful information on guiding shared decision-making conversations about anticoagulation choice, especially in a patient demographic of predominantly low socioeconomic status individuals

Background: Hypertension (HTN) is common among older adults and increases the risks for adverse outcomes. Blood pressure (BP) control for older adults is complex and nuanced, balancing medi-cation effects and competing risks. We implemented a patient-entered HTN control intervention in an urban geriatric medicine clinic.
Method(s): We identified patients with HTN at Bellevue Hospital's Geriatric Clinic age 65-75 with BPs >140/90 from the electronic medi-cal record. We asked each patient's primary care physician (PCP) to assign a BP goal and identify high-risk patients. We contacted patients determined by their PCP to need intensive BP management includ-ing medication side-effects and compliance assessment. We also developed a multi-pronged BP-control intervention clinic-wide for all patients, which included training nursing, medical assistant, and PCPs in best practices in BP measurement. We also ensured proper documentation, repeat measurement of all BP >150/90 and educa-tional materials for patients in English and Spanish. We scheduled a focused BP visit with a nurse within 2 weeks and if BP was not at goal, the patient would be seen by a physician for repeat BP measurement, compliance assessment and treatment optimization. We continued close follow up with these patients until they reached their BP goal.
Result(s): Pre-intervention, we identified 128 patients, of whom 71% had diabetes, 12% had a stroke, 20% had coronary artery disease, 15% had dementia, 8% problems with dizziness, and 69% problems with medication compliance per their PCP. The percentage of patients assigned to goal of BP<130/90 was 13%, 82% to a goal of <140/90, and 5% to a goal of <150/90. After PCP review, 42% (54 of 128) were at their specific BP goal based on home readings or proper in clinic measurement. After 4 months, among the 73 patients identified as needing further BP management, 52.1% were controlled. Clinic-wide, the percentage of patients whose blood pressure is <140/80improved from 66% to 74% within 4 months since program initiation. Our inter-vention is currently ongoing.
Conclusion(s): BP management among older adults requires indi-vidualized goals and intervention. Our interventions which empha-sized proper BP measurement and documentation, formal education of both providers and patients, and focused BP visits have improved BP control for our clinic population

Background: The AGS Choosing Wisely Workgroup recommends incorporating life expectancy in cancer screening decisions. Previous studies indicate that non-geriatricians consider prognosis important to their clinical decisions, but often do not use prognostic tools. Moreover, they rarely discuss prognosis with patients. Little is known about how geriatricians include life expectancy in cancer screening decisions or whether prognosis is discussed. Methods: We surveyed attending geriatricians and fellows who care for community-dwelling older adults in academic clinics in New York City. We inquired whether these physicians incorporate prognosis in cancer screening decisions and discuss prognosis with patients, and how they estimate prognosis; we measured their confidence in estimating and discussing prognosis (5 point Likert scale: 0="not confident at all" to 4="extremely confident"). We also examined barriers to use of 2 common prognostic tools (ePrognosis and Gait speed) and having these discussions. Results: Twelve attendings and six fellows completed surveys (72% response rate). All respondents incorporated prognosis in cancer screening decisions and discussed prognosis with patients. Respondents estimated prognosis based on clinical impression (n=16), life table (n=5), ePrognosis (n=6) and gait speed (n=2). Confidence in estimating and discussing prognosis with patients was neutral (median for both: 2; range 1-3). Attending physicians were more confident in 1) estimating and 2) discussing prognosis with patients than were fellows (median: 2 versus 1, p=0.001; median: 3 versus 1.5, p=0.01, respectively). "Lack of time" was the most frequently reported barrier to prognostic tool use and prognosis discussions with patients followed by "unfamiliarity", "lack of resources" and "uncertainty about prognosis estimates", respectively (see table). Conclusions: Geriatricians identify considerable barriers to discussing prognosis when making cancer-screening decisions. Addressing these barriers may improve confidence in estimating and discussing prognosis. (Table Presented)