Faculty Bibliography
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125
BLEEDING READMISSIONS AFTER ACUTE MYOCARDIAL INFARCTION IN OLDER ADULTS: THE SILVER-AMI STUDY [Meeting Abstract]
Background We developed a risk model to predict hospitalization for bleeding within 6 months of discharge in older adults hospitalized for acute MI (AMI) and discharged on dual antiplatelet therapy (DAPT). Methods SILVER-AMI is a cohort study of 3041 patients age >=75 hospitalized with AMI at 96 U.S. hospitals. Participants underwent in-hospital functional assessment (cognition, vision, hearing, unintentional weight loss, ADLs, grip strength, functional mobility, falls). These analyses focused on participants discharged on DAPT (N=1858). Our outcome was rehospitalization for bleeding within 6 months. We used Bayesian model averaging to develop a risk model with split sample validation. Results Mean age was 81.5 years. Compared with participants not prescribed DAPT, those prescribed DAPT had slightly better functional mobility and lower cognitive impairment. Overall, 150 (8.1%) participants on DAPT experienced hospitalization for bleeding within 6 months; nearly half (48.7%) were gastrointestinal. Rates of functional impairments were similar among participants who did and did not experience bleeding. The final risk model included 8 predictors (Table), had moderate discrimination (C-statistic = 0.66), and good calibration (Hosmer-Lemeshow P value > 0.05). Conclusion Hospitalization for bleeding within 6 months of discharge on DAPT among older AMI patients was not predicted by aging-related functional impairments, but 8 other clinically plausible predictors were identified. [Figure presented]
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EMBASE:2005042710
ISSN: 0735-1097
CID: 4367312
CARDIOVASCULAR DISEASE AND CUMULATIVE INCIDENCE OF COGNITIVE IMPAIRMENT: LONGITUDINAL FINDINGS FROM THE HEALTH AND RETIREMENT STUDY [Meeting Abstract]
Background We sought to examine whether people with a diagnosis of cardiovascular disease (CVD) experienced a greater incidence of subsequent cognitive impairment (CI) compared to people without CVD, as suggested by prior studies, using a large longitudinal cohort. Methods We used biennial data collected on adults age >=50 from the Health and Retirement Study (HRS) to compare the incidence of CI over 8 years in 1,931 participants newly diagnosed with CVD vs. 3,862 age- and gender-matched controls. Diagnosis of CVD was adjudicated with an established HRS methodology. CI was defined as <=11 on the 27-point Telephone Interview for Cognitive Status, based on a previously accepted clinical cutpoint. To examine the incidence of CI, we used a cumulative incidence function accounting for competing risk of death. Results Mean age at study entry was 70 years, and 55% were female. CI developed in 1,335 participants over 8 years. Death was more common among participants with incident CVD (20.4% vs. 13.4%, p <.001). Cumulative incidence analysis for CI, after adjusting for death, showed no significant difference in incidence of cognitive impairment between the CVD and control groups at the end of the study period (Figure). Conclusion We found no increased risk of subsequent cognitive impairment among participants with CVD (compared with no CVD), despite previous research indicating that CVD accelerates cognitive decline. This finding may be due to appropriately accounting for the competing risk of death. [Figure presented]
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EMBASE:2005039508
ISSN: 0735-1097
CID: 4367682
A Descriptive Analysis of an Ambulatory Kidney Palliative Care Program
PMID: 31295050
ISSN: 1557-7740
CID: 3976762
Determinants and outcomes of acute kidney injury among older patients undergoing invasive coronary angiography for acute myocardial infarction: The SILVER-AMI Study
BACKGROUND:Among older adults (age≥75) hospitalized for acute myocardial infarction, acute kidney injury after coronary angiography is common. Aging-related conditions may independently predict acute kidney injury, but have not yet been analyzed in large acute myocardial infarction cohorts. METHODS:We analyzed data from 2212 participants age≥75 in the SILVER-AMI study who underwent coronary angiography. Acute kidney injury was defined using KDIGO criteria (serum Cr increase ≥0.3mg/dL from baseline or≥1.5 times baseline). We analyzed the associations of traditional acute kidney injury risk factors and aging-related conditions (ADL impairment, prior falls, cachexia, low physical activity) with acute kidney injury, and then performed logistic regression to identify independent predictors. RESULTS:Participants' mean age was 81.3years, 45.2% were female, and 9.5% were nonwhite; 421 (19.0%) experienced acute kidney injury. Comorbid diseases and aging-related conditions were both more common among individuals experiencing acute kidney injury. However, after multivariable adjustment, no aging-related conditions were retained. There were 11 risk factors in the final model; the strongest were heart failure on presentation (OR 1.91, 95% CI 1.41-2.59), BMI >30 (vs. BMI 18-25: OR 1.75, 95% CI 1.27-2.42), and nonwhite race (OR 1.65, 95% CI 1.16-2.33). The final model achieved an AUC of 0.72 and was well calibrated (Hosmer-Lemeshow P=0.50). Acute kidney injury was independently associated with 6month mortality (OR 1.98, 95% CI 1.36-2.88) but not readmission (OR 1.26, 95% CI 0.98-1.61). CONCLUSIONS:Acute kidney injury is common among older adults with acute myocardial infarction undergoing coronary angiography. Predictors largely mirrored those in previous studies of younger individuals, which suggests that geriatric conditions mediate their influence through other risk factors.
PMID: 31170374
ISSN: 1555-7162
CID: 3923512
Association of Patient Priorities-Aligned Decision-Making With Patient Outcomes and Ambulatory Health Care Burden Among Older Adults With Multiple Chronic Conditions: A Nonrandomized Clinical Trial
Importance/UNASSIGNED:Health care may be burdensome and of uncertain benefit for older adults with multiple chronic conditions (MCCs). Aligning health care with an individual's health priorities may improve outcomes and reduce burden. Objective/UNASSIGNED:To evaluate whether patient priorities care (PPC) is associated with a perception of more goal-directed and less burdensome care compared with usual care (UC). Design, Setting, and Participants/UNASSIGNED:Nonrandomized clinical trial with propensity adjustment conducted at 1 PPC and 1 UC site of a Connecticut multisite primary care practice that provides care to almost 15% of the state's residents. Participants included 163 adults aged 65 years or older who had 3 or more chronic conditions cared for by 10 primary care practitioners (PCPs) trained in PPC and 203 similar patients who received UC from 7 PCPs not trained in PPC. Participant enrollment occurred between February 1, 2017, and March 31, 2018; follow-up extended for up to 9 months (ended September 30, 2018). Interventions/UNASSIGNED:Patient priorities care, an approach to decision-making that includes patients' identifying their health priorities (ie, specific health outcome goals and health care preferences) and clinicians aligning their decision-making to achieve these health priorities. Main Outcomes and Measures/UNASSIGNED:Primary outcomes included change in patients' Older Patient Assessment of Chronic Illness Care (O-PACIC), CollaboRATE, and Treatment Burden Questionnaire (TBQ) scores; electronic health record documentation of decision-making based on patients' health priorities; medications and self-management tasks added or stopped; and diagnostic tests, referrals, and procedures ordered or avoided. Results/UNASSIGNED:Of the 366 patients, 235 (64.2%) were female and 350 (95.6%) were white. Compared with the UC group, the PPC group was older (mean [SD] age, 74.7 [6.6] vs 77.6 [7.6] years) and had lower physical and mental health scores. At follow-up, PPC participants reported a 5-point greater decrease in TBQ score than those who received UC (ß [SE], -5.0 [2.04]; P = .01) using a weighted regression model with inverse probability of PCP assignment weights; no differences were seen in O-PACIC or CollaboRATE scores. Health priorities-based decisions were mentioned in clinical visit notes for 108 of 163 (66.3%) PPC vs 0 of 203 (0%) UC participants. Compared with UC patients, PPC patients were more likely to have medications stopped (weighted comparison, 52.0% vs 33.8%; adjusted odds ratio [AOR], 2.05; 95% CI, 1.43-2.95) and less likely to have self-management tasks (57.5% vs 62.1%; AOR, 0.59; 95% CI, 0.41-0.84) and diagnostic tests (80.8% vs 86.4%; AOR, 0.22; 95% CI, 0.12-0.40) ordered. Conclusions and Relevance/UNASSIGNED:This study's findings suggest that patient priorities care may be associated with reduced treatment burden and unwanted health care. Care aligned with patients' priorities may be feasible and effective for older adults with MCCs. Trial Registration/UNASSIGNED:ClinicalTrials.gov identifier: NCT03600389.
PMID: 31589281
ISSN: 2168-6114
CID: 4130502
User-Centered Development of a Behavioral Economics Inspired Electronic Health Record Clinical Decision Support Module
Changing physician behaviors is difficult. Electronic health record (EHR) clinical decision support (CDS) offers an opportunity to promote guideline adherence. Behavioral economics (BE) has shown success as an approach to supporting evidence-based decision-making with little additional cognitive burden. We applied a user-centered approach to incorporate BE "nudges" into a CDS module in two "vanguard" sites utilizing: (1) semi-structured interviews with key informants (n = 8); (2) a design thinking workshop; and (3) semi-structured group interviews with clinicians. In the 133 day development phase at two clinics, the navigator section fired 299 times for 27 unique clinicians. The inbasket refill alert fired 124 times for 22 clinicians. Fifteen prescriptions for metformin were written by 11 clinicians. Our user-centered approach yielded a BE-driven CDS module with relatively high utilization by clinicians. Next steps include the addition of two modules and continued tracking of utilization, and assessment of clinical impact of the module.
PMID: 31438106
ISSN: 1879-8365
CID: 4046992
Perspectives of Patients in Identifying Their Values-Based Health Priorities
OBJECTIVES/OBJECTIVE:Patient Health Priorities Identification (PHPI) is a values-based process in which trained facilitators assist older adults with multiple chronic conditions identify their health priorities. The purpose of this study was to evaluate patients' perceptions of PHPI. DESIGN/METHODS:Qualitative study using thematic analysis. SETTING/METHODS:In-depth semistructured telephone and in-person interviews. PARTICIPANTS/METHODS:Twenty-two older adults who participated in the PHPI process. MEASUREMENTS/METHODS:Open-ended questions about patient perceptions of the PHPI process, perceived benefits of the process, enablers and barriers to PHPI, and recommendations for process enhancement. RESULTS:Patient interviews ranged from 9 to 63 minutes (median = 20 min; interquartile range = 15-26). The mean age was 80 years (standard deviation = 7.96), 64% were female, and all patients identified themselves as white. Of the sample, 73% reported no caregiver involvement in their healthcare; 36% lived alone. Most patients felt able to complete the PHPI process with ease. Perceived benefits included increased knowledge and insight into disease processes and treatment options, patient activation, and enhanced communication with family and clinicians. Patients identified several factors that were both enablers and barriers to PHPI including facilitator characteristics, patient demographic and clinical characteristics, social support, relationships between the patient and their primary care provider, and the changing health priorities of the patient. Recommendations for process enhancement included more frequent and flexible facilitator contacts, selection of patients for participation based on specific patient characteristics, clarification of process aims and expectations, involvement of family, written reminders of established health priorities, short duration between facilitation and primary care provider follow-up, and the inclusion of health-related tasks in facilitation visits. CONCLUSIONS:Patients found the PHPI process valuable in identifying actionable health priorities and healthcare goals leading to enhanced knowledge, activation, and communication regarding their treatment options and preferences. PHPI may be useful for aligning the healthcare that patients receive with their values-based priorities.
PMID: 30844080
ISSN: 1532-5415
CID: 3759382
Functional Exercise Improves Mobility Performance in Older Adults With Type 2 Diabetes: A Randomized Controlled Trial
Background: Diabetes-related disability occurs in approximately two-thirds of older adults with diabetes and is associated with loss of independence, increased health care resource utilization, and sedentary lifestyle. The objective of this randomized controlled trial was to determine the effect of a center-based functional circuit exercise training intervention followed by a 10-week customized home-based program in improving mobility function in sedentary older adults with diabetes. Methods: Participants (n = 111; mean age 70.5 [7.1] y; mean body mass index 32.7 [5.9] kg/m2) were randomized to either a moderate-intensity functional circuit training (FCT) plus 10-week home program to optimize physical activity (FCT-PA) primary intervention or one of 2 comparison groups (FCT plus health education [FCT-HE] or flexibility and toning plus health education [FT-HE]). Results: Compared with FT-HE, FCT-PA improvements in comfortable gait speed of 0.1 m/s (P < .05) and 6-minute walk of 80 ft were consistent with estimates of clinically meaningful change. At 20 weeks, controlling for 10-week outcomes, improvements were found between groups for comfortable gait speed (FCT-PA vs FT-HE and FCT-HE vs FT-HE) and 6-minute walk (FCT-PA vs FCT-HE). Conclusions: Functional exercise training can improve mobility in overweight/obese older adults with diabetes and related comorbidities. Future studies should evaluate intervention sustainability and adaptations for those with more severe mobility impairments.
PMID: 31122111
ISSN: 1543-5474
CID: 3920932
Journal of general internal medicine. 2019:Conference:(2019):S122-S123.DOI: 10.1007/11606.1525-2D1497
Addressing overtreatment in older adults with diabetes: Leveraging behavioral economics and user-centered design to develop clinical decision support [Meeting Abstract]
Background: Older adults with diabetes continue to be overtreated despite current guidelines recommending less aggressive target A1c levels based on life expectancy. The suboptimal management of this vulnerable population could be due to physicians having conflicting beliefs regarding this guideline or simply lacking awareness, and changing these behaviors is challenging. Clinical decision support (CDS) within the electronic health record (EHR) has the potential to address this issue, but effectiveness is undermined by alert fatigue and poor workflow integration. Incorporating behavioral economics into CDS tools is an innovative approach to improve adherence to these guidelines while reducing physician burden, and offers the promise of improving care in this population.
Method(s): We applied a systematic, user-centered approach to incorporate behavioral economic " nudges" into a CDS module and performed user testing in six pilot primary care practices in a large academic medical center. To build the nudges, we conducted: (1) semi-structured interviews with key informants (n=8); (2) a two-hour design thinking workshop to derive and refine initial module ideas; and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on the module components. Clinicians were observed using the module in practice; detailed field notes were collected and summarized by module idea and usability theme for rapid iteration and refinement. Frequency of firing and user action taken were assessed in the first month of implementation via EHR reporting to confirm that module components and reporting were working as expected, and to assess utilization.
Result(s): Insights from key stakeholder and clinician group interviews identified the refill protocol, inbasket lab result, and medication preference list as candidate EHR CDS targets for the module. A new EHR navigator section notification and peer comparison message, derived from the design workshop, were also prototyped and produced. User feedback from site visits confirmed compatibility with clinical workflows, and contributed to refinement of design and content. The initial prototypes were first piloted at two sites, refined, and then activated at an additional four additional sites. Preliminary Results for the six clinics indicate that over approximately 31 weeks: 1) the navigator alert fired 1047 times for 53 unique clinicians, and 2) the refill protocol alert fired 421 times for 53 unique clinicians. Reports for the other " nudges" are in development.
Conclusion(s): Integrating behavioral economic nudges into the EHR is a promising approach to enhancing guideline awareness and adherence for older adults with diabetes. This novel pilot will demonstrate the initial feasibility and preliminary efficacy of this strategy and determine if a full-scale effectiveness trial is warranted
Method(s): We applied a systematic, user-centered approach to incorporate behavioral economic " nudges" into a CDS module and performed user testing in six pilot primary care practices in a large academic medical center. To build the nudges, we conducted: (1) semi-structured interviews with key informants (n=8); (2) a two-hour design thinking workshop to derive and refine initial module ideas; and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on the module components. Clinicians were observed using the module in practice; detailed field notes were collected and summarized by module idea and usability theme for rapid iteration and refinement. Frequency of firing and user action taken were assessed in the first month of implementation via EHR reporting to confirm that module components and reporting were working as expected, and to assess utilization.
Result(s): Insights from key stakeholder and clinician group interviews identified the refill protocol, inbasket lab result, and medication preference list as candidate EHR CDS targets for the module. A new EHR navigator section notification and peer comparison message, derived from the design workshop, were also prototyped and produced. User feedback from site visits confirmed compatibility with clinical workflows, and contributed to refinement of design and content. The initial prototypes were first piloted at two sites, refined, and then activated at an additional four additional sites. Preliminary Results for the six clinics indicate that over approximately 31 weeks: 1) the navigator alert fired 1047 times for 53 unique clinicians, and 2) the refill protocol alert fired 421 times for 53 unique clinicians. Reports for the other " nudges" are in development.
Conclusion(s): Integrating behavioral economic nudges into the EHR is a promising approach to enhancing guideline awareness and adherence for older adults with diabetes. This novel pilot will demonstrate the initial feasibility and preliminary efficacy of this strategy and determine if a full-scale effectiveness trial is warranted
EMBASE:629001208
ISSN: 1525-1497
CID: 4053282
Reasons geriatrics fellows choose geriatrics as a career, and implications for workforce recruitment
OBJECTIVES/OBJECTIVE:Although the population of older adults is rising, the number of physicians seeking geriatrics training is decreasing. This study of fellows in geriatrics training programs across the United States explored motivating factors that led fellows to pursue geriatrics in order to inform recruitment efforts. DESIGN/METHODS:Semi-structured telephone interviews with geriatrics fellows. SETTING/METHODS:Academic medical centers. PARTICIPANTS/METHODS:Fifteen geriatrics fellows from academic medical centers across the United States. MEASUREMENTS/METHODS:This qualitative telephone study involved interviews that were transcribed and descriptively coded by two independent reviewers. A thematic analysis of the codes was summarized. RESULTS:Fellows revealed that mentorship and early exposure to geriatrics were the most influential factors affecting career choice. CONCLUSION/CONCLUSIONS:The results of this study have the potential for a large impact, helping to inform best practices in encouraging trainees to enter the field, and enhancing medical student and resident exposure to geriatrics.
PMID: 30999816
ISSN: 1545-3847
CID: 3810642
