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Analgesic prescribing trends in a national sample of older veterans with osteoarthritis: 2012-2017
Trentalange, Mark; Runels, Tessa; Bean, Andrew; Kerns, Robert D; Bair, Matthew J; Brody, Abraham A; Brandt, Cynthia A; Hwang, Ula
Few investigations examine patterns of opioid and nonopioid analgesic prescribing and concurrent pain intensity ratings before and after institution of safer prescribing programs such as the October 2013 Veterans Health Administration system-wide Opioid Safety Initiative (OSI) implementation. We conducted a quasi-experimental pre-post observational study of all older U.S. veterans (≥50 years old) with osteoarthritis of the knee or hip. All associated outpatient analgesic prescriptions and outpatient pain intensity ratings from January 1, 2012 to December 31, 2016, were analyzed with segmented regression of interrupted time series. Standardized monthly rates for each analgesic class (total, opioid, nonsteroidal anti-inflammatory drug, acetaminophen, and other study analgesics) were analyzed with segmented negative binomial regression models with overall slope, step, and slope change. Similarly, segmented linear regression was used to analyze pain intensity ratings and percentage of those reporting pain. All models were additionally adjusted for age, sex, and race. Before OSI implementation, total analgesic prescriptions showed a steady rise, abruptly decreasing to a flat trajectory after OSI implementation. This trend was primarily due to a decrease in opioid prescribing after OSI. Total prescribing after OSI implementation was partially compensated by continuing increased prescribing of other study analgesics as well as a significant rise in acetaminophen prescriptions (post-OSI). No changes in nonsteroidal anti-inflammatory drug prescribing were seen. A small rise in the percentage of those reporting pain but not mean pain intensity ratings continued over the study period with no changes associated with OSI. Changes in analgesic prescribing trends were not paralleled by changes in reported pain intensity for older veterans with osteoarthritis.
PMID: 30913167
ISSN: 1872-6623
CID: 5079842
An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department
Moss, Jason M; Bryan, William E; Wilkerson, Loren M; King, Heather A; Jackson, George L; Owenby, Ryan K; Van Houtven, Courtney H; Stevens, Melissa B; Powers, James; Vaughan, Camille P; Hung, William W; Hwang, Ula; Markland, Alayne D; Sloane, Richard; Knaack, William; Hastings, Susan Nicole
OBJECTIVE:To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician-pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED). METHODS:This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention. RESULTS:Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug-disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001). CONCLUSION/CONCLUSIONS:Academic detailing led by a physician-pharmacist pair resulted in improved confidence in physician residents' ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.
PMCID:6533068
PMID: 29277130
ISSN: 1531-1937
CID: 5648832
ACE Model for Older Adults in ED
Sanon, Martine; Hwang, Ula; Abraham, Gallane; Goldhirsch, Suzanne; Richardson, Lynne D; ,
The emergency department (ED) is uniquely positioned to improve care for older adults and affect patient outcome trajectories. The Mount Sinai Hospital ED cares for 15,000+ patients >65 years old annually. From 2012 to 2015, emergency care in a dedicated Geriatric Emergency Department (GED) replicated an Acute Care for Elderly (ACE) model, with focused assessments on common geriatric syndromes and daily comprehensive interdisciplinary team (IDT) meetings for high-risk patients. The IDT, comprised of an emergency physician, geriatrician, transitional care nurse (TCN) or geriatric nurse practitioner (NP), ED nurse, social worker (SW), pharmacist (RX), and physical therapist (PT), developed comprehensive care plans for vulnerable older adults at high risk for morbidity, ED revisit, functional decline, or potentially avoidable hospital admission. Patients were identified using the Identification of Seniors at Risk (ISAR) screen, followed by geriatric assessments to assist in the evaluation of elders in the ED. On average, 38 patients per day were evaluated by the IDT with approximately 30% of these patients formally discussed during IDT rounds. Input from the IDT about functional and cognitive, psychosocial, home safety, and pharmacological assessments influenced decisions on hospital admission, care transitions, access to community based resources, and medication management. This paper describes the role of a Geriatric Emergency Medicine interdisciplinary team as an innovative ACE model of care for older adults who present to the ED.
PMCID:6473391
PMID: 31023992
ISSN: 2308-3417
CID: 5649022
Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients
Perry, William; Lacritz, Laura; Roebuck-Spencer, Tresa; Silver, Cheryl; Denney, Robert L; Meyers, John; McConnel, Charles E; Pliskin, Neil; Adler, Deb; Alban, Christopher; Bondi, Mark; Braun, Michelle; Cagigas, Xavier; Daven, Morgan; Drozdick, Lisa; Foster, Norman L; Hwang, Ula; Ivey, Laurie; Iverson, Grant; Kramer, Joel; Lantz, Melinda; Latts, Lisa; Ling, Shari M; Lopez, Ana Maria; Malone, Michael; Martin-Plank, Lori; Maslow, Katie; Melady, Don; Messer, Melissa; Most, Randi; Norris, Margaret P; Shafer, David; Silverberg, Nina; Thomas, Colin M; Thornhill, Laura; Tsai, Jean; Vakharia, Nirav; Waters, Martin; Golden, Tamara
In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition; emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; and recognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time. Summit Participants Deb Adler1, Christopher Alban, MD, MBA2, Mark Bondi, PhD3, Michelle Braun, PhD4, Xavier Cagigas, PhD5, Morgan Daven6, Robert L. Denney, PsyD7,8, Lisa Drozdick, PhD9, Norman L. Foster, MD10,11, Ula Hwang, MD12–15, Laurie Ivey, PsyD16, Grant Iverson, PhD7,17, Joel Kramer, PsyD18, Laura Lacritz, PhD7,19, Melinda Lantz, MD20, Lisa Latts, MD, MSPH, MBA21, Shari M. Ling, MD22, Ana Maria Lopez, MD23–26, Michael Malone, MD27,28, Lori Martin-Plank, PhD, MSN, MSPH, RN29, Katie Maslow, MSW30, Don Melady, MSc(Ed), MD31–33, Melissa Messer34, John Meyers, PsyD7, Charles E. McConnel, PhD19, Randi Most, PhD36, Margaret P. Norris, PhD37, William Perry, PhD7,85,39, Neil Pliskin, PhD40, David Shafer, MBA41, Nina Silverberg, PhD42, Tresa Roebuck-Spencer, PhD43,44, Colin M. Thomas, MD, MPH45, Laura Thornhill, JD46, Jean Tsai, MD, PhD10,47, Nirav Vakharia, MD48, Martin Waters, MSW49 Organizations Represented Alzheimer’s Association, Chicago, IL AMA/CPT Health Care Professionals Advisory Committee, Chicago, IL American Academy of Clinical Neuropsychology (AACN), Ann Arbor, MI American Academy of Neurology (AAN), Minneapolis, MN American Association of Geriatric Psychiatry (AAGP), McLean, VA American Association of Nurse Practitioners (AANP), Austin, TX American Board of Professional Neuropsychology (ABN), Sarasota, FL American College of Emergency Physicians (ACEP), Philadelphia, PA American College of Physicians (ACP), Philadelphia, PA American Geriatrics Society (AGS), New York, NY American Psychological Association (APA), Washington, DC Beacon Health Options, Boston, MA Canadian Association of Emergency Physicians, Ottawa, ON, Canada Collaborative Family Healthcare Association (CFHA), Rochester, New York Gerontological Society of America, Washington, DC Hispanic Neuropsychological Society (HNS), Los Angeles, CA IBM Watson Health, Denver, CO International Federation of Emergency Medicine, West Melbourne, Australia International Neuropsychological Society (INS), Salt Lake City, UT National Academy of Neuropsychology (NAN), Denver, CO Optum of UnitedHealth Group, Minneapolis, MN Pearson, New York City, New York Psychological Assessment Resources, Inc, Lutz, FL Society for Clinical Neuropsychology, Washington, DC U.S. Department of Veterans Affairs, Washington, DC *Please note that participation in the Summit does not constitute organizational endorsement of this report
PMCID:6201735
PMID: 30339202
ISSN: 1873-5843
CID: 5648932
Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients
Perry, William; Lacritz, Laura; Roebuck-Spencer, Tresa; Silver, Cheryl; Denney, Robert L; Meyers, John; McConnel, Charles E; Pliskin, Neil; Adler, Deb; Alban, Christopher; Bondi, Mark; Braun, Michelle; Cagigas, Xavier; Daven, Morgan; Drozdick, Lisa; Foster, Norman L; Hwang, Ula; Ivey, Laurie; Iverson, Grant; Kramer, Joel; Lantz, Melinda; Latts, Lisa; Ling, Shari M; Maria Lopez, Ana; Malone, Michael; Martin-Plank, Lori; Maslow, Katie; Melady, Don; Messer, Melissa; Most, Randi; Norris, Margaret P; Shafer, David; Silverberg, Nina; Thomas, Colin M; Thornhill, Laura; Tsai, Jean; Vakharia, Nirav; Waters, Martin; Golden, Tamara
In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition;emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; andrecognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.
PMCID:6183165
PMID: 30480142
ISSN: 2399-5300
CID: 5648952
Bouncing Back Elsewhere: Multilevel Analysis of Return Visits to the Same or a Different Hospital After Initial Emergency Department Presentation
Shy, Bradley D; Loo, George T; Lowry, Tina; Kim, Eugene Y; Hwang, Ula; Richardson, Lynne D; Shapiro, Jason S
STUDY OBJECTIVE:Analyses of 72-hour emergency department (ED) return visits are frequently used for quality assurance purposes and have been proposed as a means of measuring provider performance. These analyses have traditionally examined only patients returning to the same hospital as the initial visit. We use a health information exchange network to describe differences between ED visits resulting in 72-hour revisits to the same hospital and those resulting in revisits to a different site. METHODS:We examined data from a 31-hospital health information exchange of all ED visits during a 5-year period to identify 72-hour return visits and collected available encounter, patient, and hospital variables. Next, we used multilevel analysis of encounter-level, patient-level, and hospital-level data to describe differences between initial ED visits resulting in different-site and same-site return visits. RESULTS:We identified 12,621,159 patient visits to the 31 study EDs, including 841,259 same-site and 107,713 different-site return visits within 72 hours of initial ED presentation. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for the initial-visit characteristics' predictive relationship that any return visit would be at a different site: daytime visit (OR 1.10; 95% CI 1.07 to 1.12), patient-hospital county concordance (OR 1.40; 95% CI 1.36 to 1.44), male sex (OR 1.27; 95% CI 1.24 to 1.30), aged 65 years or older (OR 0.55; 95% CI 0.53 to 0.57), sites with an ED residency (OR 0.41; 95% CI 0.40 to 0.43), sites at an academic hospital (OR 1.12; 95% CI 1.08 to 1.15), sites with high density of surrounding EDs (OR 1.73; 95% CI 1.68 to 1.77), and sites with a high frequency of same-site return visits (OR 0.10; 95% CI 0.10 to 0.11). CONCLUSION:This analysis describes how ED encounters with early revisits to the same hospital differ from those with revisits to a second hospital. These findings challenge the use of single-site return-visit frequency as a quality measure, and, more constructively, describe how hospitals can use health information exchange to more accurately identify early ED return visits and to support programs related to these revisits.
PMID: 28967514
ISSN: 1097-6760
CID: 5648772
Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use
Hwang, Ula; Dresden, Scott M; Rosenberg, Mark S; Garrido, Melissa M; Loo, George; Sze, Jeremy; Gravenor, Stephanie; Courtney, D Mark; Kang, Raymond; Zhu, Carolyn W; Vargas-Torres, Carmen; Grudzen, Corita R; Richardson, Lynne D
OBJECTIVES/OBJECTIVE:To examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use. DESIGN/METHODS:Prospective observational cohort. SETTING/METHODS:Three U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015. PARTICIPANTS/METHODS:Individuals aged 65 and older in the ED (N = 57,287). INTERVENTION/METHODS:The intervention was first TCN contact. Controls never saw a TCN during the study period. MEASUREMENTS/METHODS:We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits. RESULTS:A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%). CONCLUSION/CONCLUSIONS:Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.
PMID: 29318583
ISSN: 1532-5415
CID: 2987792
Improving Emergency Department Discharge Care with Telephone Follow-Up. Does It Connect? [Comment]
Hwang, Ula; Hastings, S Nicole; Ramos, Katherine
PMID: 29272032
ISSN: 1532-5415
CID: 5648822
Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients
Perry, William; Lacritz, Laura; Roebuck-Spencer, Tresa; Silver, Cheryl; Denney, Robert L; Meyers, John; McConnel, Charles E; Pliskin, Neil; Adler, Deb; Alban, Christopher; Bondi, Mark; Braun, Michelle; Cagigas, Xavier; Daven, Morgan; Drozdick, Lisa; Foster, Norman L; Hwang, Ula; Ivey, Laurie; Iverson, Grant; Kramer, Joel; Lantz, Melinda; Latts, Lisa; Maria Lopez, Ana; Malone, Michael; Martin-Plank, Lori; Maslow, Katie; Melady, Don; Messer, Melissa; Most, Randi; Norris, Margaret P; Shafer, David; Thomas, Colin M; Thornhill, Laura; Tsai, Jean; Vakharia, Nirav; Waters, Martin; Golden, Tamara
In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition; emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; and recognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.
PMID: 30396329
ISSN: 1744-4144
CID: 5648942
Using music to reduce anxiety among older adults in the emergency department: a randomized pilot study
Belland, Laura; Rivera-Reyes, Laura; Hwang, Ula
BACKGROUND:An emergency department (ED) visit may be distressing and anxiety-provoking for older adults (age > 65 years). No studies have specifically evaluated the effect of music listening on anxiety in older adults in the ED. OBJECTIVE:The objective of this pilot study was to evaluate the effect of music listening on anxiety levels in older ED patients. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS/METHODS:This was a randomized pilot study in the geriatric ED of an urban academic tertiary medical center. This was a sample of English-speaking adults (age > 65 years) who were not deaf (n = 35). Subjects consented to participate and were randomized to receive up to 60 min of music listening with routine care, while the control group received routine care with no music. Subjects in the music treatment group received headphones and an electronic tablet with pre-downloaded music, and were allowed to choose from 5 selections. MAIN OUTCOME MEASURES/METHODS:The primary outcome was change in anxiety levels, measured by the state-trait anxiety inventory (STAI), at enrollment and 1 h later. RESULTS:A total of 35 participants were enrolled: 74% were female, 40% were white, and 40% were black; of these, 32 subjects completed the study protocol. When comparing control (n = 18) against intervention subjects (n = 17), there were no significant differences in enrollment STAI scores (43.00 ± 15.00 vs. 40.30 ± 12.80, P = 0.57). STAI scores 1 hour after enrollment (after the music intervention) were significantly reduced in the intervention subjects compared to the control subjects (with reduction of 10.00 ± 12.29 vs. 1.88 ± 7.97, P = 0.03). CONCLUSION/CONCLUSIONS:These pilot results suggest that music listening may be an effective tool for reducing anxiety among older adults in the ED.
PMID: 29103414
ISSN: 2095-4964
CID: 5648792