Faculty Bibliography

Background/UNASSIGNED:Current guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes. The effectiveness of electronic health record (EHR) clinical decision support (CDS) in promoting guideline adherence is undermined by alert fatigue and poor workflow integration. Integrating behavioral economics (BE) and CDS tools is a novel approach to improving adherence to guidelines while minimizing clinician burden. Methods/UNASSIGNED: = 8), (2) a 2-h, 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 three proposed nudge module components (navigator section, inbasket refill protocol, medication preference list). Detailed field notes will be summarized by module idea and usability theme for rapid iteration. Frequency of firing and user action taken will be assessed in the first month of implementation via EHR reporting to confirm that module components and related reporting are working as expected as well as assess utilization. To assess the utilization and feasibility of the new tools and generate estimates of clinician compliance with the Choosing Wisely guideline for diabetes management in older adults, a 6-month, single-arm pilot study of the BE-EHR module will be conducted in six outpatient primary care clinics. Discussion/UNASSIGNED:We hypothesize that a low burden, user-centered approach to design will yield a BE-driven, CDS module with relatively high utilization by clinicians. The resulting module will establish a platform for exploring the ability of BE concepts embedded within the EHR to affect guideline adherence for other use cases.

OBJECTIVES/OBJECTIVE:To develop a values-based, clinically feasible process to help older adults identify health priorities that can guide clinical decision-making. DESIGN/METHODS:Prospective development and feasibility study. SETTING/METHODS:Primary care practice in Connecticut. PARTICIPANTS/METHODS:Older adults with 3 or more conditions or taking 10 or more medications (N=64). INTERVENTION/METHODS:The development team of patients, caregivers, and clinicians used a user-centered design framework-ideate → prototype → test →redesign-to develop and refine the value-based patient priorities care process and medical record template with trained clinician facilitators. MEASUREMENTS/METHODS:We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions). RESULTS:We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians. CONCLUSION/CONCLUSIONS:Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.

Older adults with multiple chronic conditions (MCCs) receive care that is fragmented and burdensome, lacks evidence, and most importantly is not focused on what matters most to them. An implementation feasibility study of Patient Priorities Care (PPC), a new approach to care that is based on health outcome goals and healthcare preferences, was conducted. This study took place at 1 primary care and 1 cardiology practice in Connecticut and involved 9 primary care providers (PCPs), 5 cardiologists, and 119 older adults with MCCs. PPC was implemented using methods based on a practice change framework and continuous plan-do-study-act (PDSA) cycles. Core elements included leadership support, clinical champions, priorities facilitators, training, electronic health record (EHR) support, workflow development and continuous modification, and collaborative learning. PPC processes for clinic workflow and decision-making were developed, and clinicians were trained. After 10 months, 119 older adults enrolled and had priorities identified; 92 (77%) returned to their PCP after priorities identification. In 56 (46%) of these visits, clinicians documented patient priorities discussions. Workflow challenges identified and solved included patient enrollment lags, EHR documentation of priorities discussions, and interprofessional communication. Time for clinicians to provide PPC remains a challenge, as does decision-making, including clinicians' perceptions that they are already doing so; clinicians' concerns about guidelines, metrics, and unrealistic priorities; and differences between PCPs and patients and between PCPs and cardiologists about treatment decisions. PDSA cycles and continuing collaborative learning with national experts and peers are taking place to address workflow and clinical decision-making challenges. Translating disease-based to priorities-aligned decision-making appears challenging but feasible to implement in a clinical setting.

More than 13 million persons in the United States aged 65 and older have cardiovascular disease (CVD), and this population is expected to increase exponentially over the next several decades. In the absence of clinical studies that would inform how best to manage this population, there is an urgent need for collaborative, thoughtful approaches to their care. Although cardiologists are traditionally regarded as leaders in the care of older adults with CVD, these individuals have multiple comorbidities, physiological differences, and distinct goals of care than younger patients that require a specialized geriatric lens. Thus, collaboration is needed between geriatricians, cardiologists, and other specialists to address the unique needs of this growing population. Accordingly, clinicians at New York University Langone Health and School of Medicine established a monthly Geriatric Cardiology Conference to foster an integrative approach to the care of older adults with CVD by uniting specialists across disciplines to collaborate on treatment strategies. At each conference, an active case is discussed and analyzed in detail, and a consensus is reached among participants regarding optimal treatment strategies. The conference attracts faculty and trainees at multiple levels from geriatrics, cardiology, and cardiothoracic surgery. The model may serve as a paradigm for other institutions moving towards geriatric-informed care of older adults with CVD.

OBJECTIVES: Chronic disease data from longitudinal health interview surveys are frequently used in epidemiologic studies. These data may be limited by inconsistencies in self-report by respondents across waves. We examined disease inconsistencies in the Health and Retirement Study and investigated a multistep method of adjudication. We hypothesized a greater likelihood of inconsistences among respondents with cognitive impairment, of underrepresented race/ethnic groups, having lower education, or having less income/wealth. METHOD: We analyzed Waves 1995-2010, including adults 51 years and older (N = 24,156). Diseases included hypertension, heart disease, lung disease, diabetes, cancer, stroke, and arthritis. We used questions about the diseases to formulate a multistep adjudication method to resolve inconsistencies across waves. RESULTS: Thirty percent had inconsistency in their self-report of diseases across waves, with cognitive impairment, proxy status, age, Hispanic ethnicity, and wealth as key predictors. Arthritis and hypertension had the most frequent inconsistencies; stroke and cancer, the fewest. Using a stepwise method, we adjudicated 60%-75% of inconsistent responses. DISCUSSION: Discrepancies in the self-report of diseases across multiple waves of health interview surveys are common. Differences in prevalence between original and adjudicated data may be substantial for some diseases and for some groups, (e.g., the cognitively impaired).

OBJECTIVE:To ascertain perspectives of multiple stakeholders on contributors to inappropriate care for older adults with multiple chronic conditions. METHOD/METHODS:Perspectives of 36 purposively sampled patients, clinicians, health systems, and payers were elicited. Data analysis followed a constant comparative method. RESULTS:Structural factors triggering burden and fragmentation include disease-based quality metrics and need to interact with multiple clinicians. The key cultural barrier identified is the assumption that "physicians know best." Inappropriate decision making may result from inattention to trade-offs and adherence to multiple disease guidelines. Stakeholders recommended changes in culture, structure, and decision making. Care options and quality metrics should reflect a focus on patients' priorities. Clinician-patient partnerships should reflect patients knowing their health goals and clinicians knowing how to achieve them. Access to specialty expertise should not require visits. DISCUSSION/CONCLUSIONS:Stakeholders' recommendations suggest health care redesigns that incorporate patients' health priorities into care decisions and realign relationships across patients and clinicians.