Faculty Bibliography

Over the past decade, hearing loss has emerged as a key issue for aging and health. We describe why hearing loss may be especially disabling in nursing home settings and provide an estimate of prevalence using the Minimum Data Set (MDS v.3.0). We outline steps to mitigate hearing loss. Many solutions are inexpensive and low-tech, but require significant awareness and institutional commitment.

Innovative geriatric clinical programs have proliferated in the 21st century, and many have been highlighted in the Journal of the American Geriatrics Society (JAGS). The Affordable Care Act has supported the accelerated innovation of publicized and unpublicized program development, adaptation, and implementation. Many JAGS articles report work conducted in programs with significant improvements in quality; high satisfaction for patients and providers; and for some, reductions in costs. Despite considerable detail, enabling implementers to attempt to adopt reported programs or adapt them to local environments, much less is typically conveyed about the subtleties of the implementation process that led to a successful outcome. Moreover, where we have been given a window into successful initiatives, far less is known about those that failed and even less about why some succeeded but others failed. With a focus on our shared needs as a geriatrics community, to foster the exchange of more-comprehensive models of successful and failed implementation, we propose publications that address implementation itself-a second layer of reporting about the "hidden" elements that may have been decisive factors in taking an efficacious test, treatment, or model and putting it into real-world practice. We propose a new platform for sharing a broader range of healthcare quality improvement initiatives-successes and failures. We include several salient characteristics that could be measured and described in support of dynamic, sustainable, evidence-based implementation of geriatrics programs.

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)

BACKGROUND:Through diet and exercise interventions, community centers offer an opportunity to address health-related issues for some of the oldest, most vulnerable members of our society. OBJECTIVES/OBJECTIVE:The purpose of this investigation is to draw upon nationwide data to better characterize the population served by the congregate meals program and to gather more detailed information on a local level to identify opportunities for service enhancement to improve the health and well-being of older adults. DESIGN/METHODS:We examined community center data from two sources: 2015 National Survey of Older Americans Act and surveys from two New York City community centers. To assess nationwide service delivery, we analyzed participant demographics, functional status defined by activities of daily living, and perceptions of services received. MEASUREMENTS/METHODS:Participants from the two New York City community centers completed a four-day food record. Functional measures included the short physical performance battery, self-reported physical function, grip strength, and the Montreal Cognitive Assessment. RESULTS:Nationwide (n=901), most participants rated the meal quality as good to excellent (91.7%), and would recommend the congregate meals program to a friend (96.0%). Local level data (n=22) were collected for an in-depth understanding of diet, physical activity patterns, body weight, and objective functional status measures. Diets of this small, local convenience sample were higher in fat, cholesterol, and sodium, and lower in calcium, magnesium, and fiber than recommended by current United States Dietary Guidelines. Average time engaged in moderate physical activity was 254 minutes per week (SD=227), exceeding the recommended 150 minutes per week, but just 41% (n=9) and 50% (n=11) of participants engaged in strength or balance exercises, respectively. CONCLUSION/CONCLUSIONS:Research is warranted to test whether improvements in the nutritional quality of food served and access/supports for engaging in strength training within community centers could help older adults achieve diet and physical activity recommendations.

There is now an unprecedented opportunity to improve the care of the over 5 million people who are living with Alzheimer's disease and related dementias and many more with cognitive impairment due to brain injury, systemic diseases, and other causes. The introduction of a new Medicare care planning benefit-long sought openly by advocacy organizations and clinicians and badly needed by patients and families-could greatly improve health care quality, but only if widely and fully implemented. We describe the components of this new benefit and its promise of better clinical care, as well as its potential to create a new platform for clinical and health outcomes research. We highlight external factors-and some that are internal to the benefit structure itself-that challenge the full realization of its value, and we call for broad public and professional engagement to ensure that it will not fail.

Hearing loss is remarkably prevalent in the geriatric population: one-quarter of adults aged 60-69 and 80% of adults aged 80 years and older have bilateral disabling loss. Only about one in five adults with hearing loss wears a hearing aid, leaving many vulnerable to poor communication with healthcare providers. We quantified the extent to which hearing loss is mentioned in studies of physician-patient communication with older patients, and the degree to which hearing loss is incorporated into analyses and findings. We conducted a structured literature search within PubMed for original studies of physician-patient communication with older patients that were published since 2000, using the natural language phrase "older patient physician communication." We identified 409 papers in the initial search, and included 67 in this systematic review. Of the 67 papers, only 16 studies (23.9%) included any mention of hearing loss. In six of the 16 studies, hearing loss was mentioned only; in four studies, hearing loss was used as an exclusion criterion; and in two studies, the extent of hearing loss was measured and reported for the sample, with no further analysis. Three studies examined or reported on an association between hearing loss and the quality of physician-patient communication. One study included an intervention to temporarily mitigate hearing loss to improve communication. Less than one-quarter of studies of physician-elderly patient communication even mention that hearing loss may affect communication. Methodologically, this means that many studies may have omitted an important potential confounder. Perhaps more importantly, research in this field has largely overlooked a highly prevalent, important, and remediable influence on the quality of communication.

Background: The National Committee for Quality Assurance (NCQA) developed the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures to evaluate health plan performance against benchmarks or other plans. The Center for Medicare and Medicaid Services (CMS) requires insurance plans to submit HEDIS data to qualify as a Medicare Advantage Plan (MAP) or a MAP that includes Medicare Part D (MAPD). Our MAPD selected and tested HEDIS and other 5-Star measures comparing the quality of care for MAPD members who did and did not use a Geriatric Assessment Center (GAC) serving MAPD members within a markedly impoverished region in the western US. Members visit the GAC typically once per year. Methods: We selected eight measures reflecting preventive care, chronic disease management, and continuity of care (See Table). Within one Medical Group, we compared the performance of these measures for Plan Members having attended the GAC in 2014 with Plan members who did not but had at least one primary care provider (PCP) visit. We used exact match procedures to identify a comparison group based on age, gender, Low-Income Subsidy Level, Risk Adjustment Factor and Special Needs Plan. Results: We identified 258 members who used the GAC in 2014 and 258 as the matched control group (See Table). Preventive care but not chronic disease management performance measures were significantly better for members who used the GAC. GAC users had better care continuity performance (measured by readmission rates) but this was not statistically significant. Conclusions: The GAC is well suited to achieving high quality preventive care due to the ease of completion in one visit. Chronic disease management care continuity is likely better suited to a repeated visit care structure. (Table Presented)

Background: A comprehensive geriatric assessment clinic (GAC) was established in collaboration with a health plan within a markedly impoverished region in the US. Evaluation objectives were to assess the quality of chronic illness care from the perspective of member-patients and providers. Methods: We abstracted medical records of patients attending the GAC during one quarter of 2014 and administered the 20-item Patient Assessment of Chronic Illness Care (PACIC) survey in English and Spanish in 2015. We anonymously surveyed patients before and directly after visits. Survey questions, modified for low health literacy, used a 1-to-5-likert scale (1=none of the time to 5=always) for 5 domains: patient activation, decision support, goal setting, problem solving, and care coordination. We administered a 7-item quality assessment survey to providers for: relevance, ease of use, ability to apply findings, and agreement with diagnostic findings and recommendations, using a 1-to-5-likert scale (1=strongly disagree to 5=strongly agree). Results: Abstracted data for 193 patients demonstrated 51% had not finished high school and their chronic condition burden was high (mean: 7.2 conditions; 31% with diabetes). For patient surveys (n=165; 19% Spanish), post-visit PACIC domain scores ranged from 4.0-4.5 and post-visit ratings were higher across all domains (1.4 to 1.7 higher; p<0.001 for each). For each of 20 questions, aggregate post scores improved, indicating higher quality. For provider surveys, respondents (n=14) felt the GAC provided useful (50%) and relevant (64%) information for their practices, taught them how to provide better care for other patients (64%), and made it easier to provide care (50%). Less than one third (29%) felt their experience discouraged them from using the service again. Discussion: The AC greatly improved member-perceived care quality and facilitated provider care among patients with high chronic condition burden, suggesting a useful strategy for patients with high need. Since some providers did not find this service useful, provider focus groups are underway to understand and improve unmet provider needs