Faculty Bibliography

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.

CONTEXT: A diagnosis of advanced chronic kidney disease (CKD), or end stage renal disease (ESRD) represents a significant life change for patients and families. Individuals often experience high symptom burden, decreased quality of life, increased health care utilization, and end-of-life care discordant with their preferences. Early integration of palliative care with standard nephrology practice in the outpatient setting has the potential to improve quality of life through provision of expert symptom management, emotional support, and facilitation of advance care planning that honors the individual's values and goals. OBJECTIVES: This special report describes application of participatory action research (PAR) methods to develop an outpatient integrated nephrology and palliative care program. METHODS: Stakeholder concerns were thematically analyzed to inform translation of a known successful model of outpatient kidney palliative care to a practice in a large, urban medical center in the United States. RESULTS: Stakeholder needs and challenges to meeting these needs were identified. We uncovered a shared understanding of the clinical need for palliative care services in nephrology practice, but apprehension towards practice change. Action steps to modify the base model were created in response to stakeholder feedback. CONCLUSIONS: The development of a model of care that provides a new approach to clinical practice requires attention to relevant stakeholder concerns. PAR is a useful methodological approach that engages stakeholders and builds partnerships. This creation of shared ownership can facilitate innovation and practice change. We synthesized stakeholder concerns to build a conceptual model for an integrated nephrology and palliative care clinical program.

BACKGROUND: Research suggests that fall risk among older adults varies by racial/ethnic groups; however, few studies have examined fall risk among Hispanics and Asian American older adults. METHODS: Using 2011-2012 California Health Interview Survey data, this study examines falling >/=2 times in the past year by racial/ethnic groups (Asian Americans, Hispanics, and Blacks) aged >/=65, adjusting for socio-demographic characteristics, body mass index, co-morbidities, and functional limitations. A secondary analysis examines differences in fall risk by English language proficiency and race/ethnicity among Asian Americans and Hispanics. RESULTS: Asian Americans were significantly less likely to fall compared to non-Hispanic whites, individuals with >/=2 chronic diseases were significantly more likely to fall than individuals with <2 chronic diseases, and many functional limitations were significantly associated with fall risk, when adjusting for all factors. African Americans and Hispanics did not differ significantly from non-Hispanic whites. Analysis adjusting for race/ethnicity and English language proficiency found that limited English proficient Asian Americans were significantly less likely to fall compared to non-Hispanic whites, individuals with >/=2 chronic diseases were significantly more likely to fall than individuals with <2 chronic diseases, and all functional limitations were significantly associated with fall risk, when adjusting for all factors. No differences were found when examining by racial/ethnic and English proficient/limited English proficient groups. CONCLUSION: Further research is needed to explore factors associated with fall risks across racial/ethnic groups. Culturally relevant and targeted interventions are needed to prevent falls and subsequent injuries in the increasingly diverse aging population in the USA.

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).

OBJECTIVES/OBJECTIVE:In 2009 and 2010, 17 primary care sites within 1 healthcare system became patient-centered medical homes (PCMHs), but the sites trained different personnel (pharmacists vs nurses) to improve diabetes care using self-management support (SMS). We report the challenges and successes of our efforts to: 1) assemble a new multipayer (Medicare, Medicaid, commercial) claims dataset linked to a clinical registry and 2) use the new dataset to perform comparative effectiveness research on implementation of the 2 SMS models. STUDY DESIGN/METHODS:Longitudinal cohort study. METHODS:We lost permission to use private-payer data. Therefore, we used claims from Medicare fee-for-service and Medicare/Medicaid dual-eligible patients merged with chronic disease registry data. We studied 2008 to 2010, which included 1 year pre- and 1 year post the 2009 implementation time period. Outcomes were outpatient and emergency department visits, hospitalizations, care process (use of statin), and 3 intermediate outcomes (glycemic control, blood pressure [BP], and low-density lipoprotein cholesterol [LDL-C]). RESULTS:In our sample of 2826 patients, quality of care improved and utilization decreased over the 2.5 years. Both approaches improved lipid control (LDL-C decreased by an average of 4 mg/dL for pharmacy-SMS and 5.6 mg/dL for nurse-SMS) and diastolic BP (-1.5 mm Hg for pharmacy-SMS and -1.3 mm Hg for nurse-SMS), whereas only the pharmacy-led approach decreased primary care visits (by 0.8 visits). The groups differed slightly on 2 measures (glycated hemoglobin, systolic BP) with respect to the trajectory of improvement over time, but performance was similar by 2.5 years. CONCLUSIONS:Diabetes care improved during PCMH implementation systemwide, supporting both nurse-led and pharmacist-led SMS models.

Although the field of frailty research has expanded rapidly, it is still a nascent concept within the clinical specialties. Frailty, conceptualized as greater vulnerability to stressors because of significant depletion of physiological reserves, predicts poorer outcomes in several medical specialties, including cardiology, human immunodeficiency virus care, and nephrology, and in the behavioral and social sciences. Lack of a consensus definition, proliferation of measurement tools, inadequate understanding of the biology of frailty, and lack of validated clinical algorithms for frail individuals hinders incorporation of frailty assessment and frailty research into the specialties. In 2015, the American Geriatrics Society, the National Institute on Aging (NIA), and the Alliance for Academic Internal Medicine held a conference for awardees of the NIA-sponsored Grants for Early Medical/Surgical Specialists Transition into Aging Research program to review the current state of knowledge regarding frailty in the subspecialties and to highlight examples of integrating frailty research into the medical specialties. Research questions to advance frailty research into specialty medicine are proposed.

BACKGROUND: Nearly 17% of patients are readmitted within 30 days of discharge after transcatheter aortic valve replacement. Selected patients are discharged to skilled nursing facilities, yet the association between a hospital's practice to discharge home versus to skilled nursing facilities, and readmission remains unclear. METHODS AND RESULTS: The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) Registry was used to evaluate readmissions among patients undergoing transcatheter aortic valve replacement (2011-2015). Hospitals were divided into quartiles (Q1-Q4) based on the percentage of patients discharged directly home. We assessed patient and hospital level characteristics and used hierarchical logistic regression to analyze the association of discharge disposition with 30-day readmission. Our cohort included 18 568 transcatheter aortic valve replacement patients at 329 US hospitals, of whom 69% were discharged directly home. Hospitals in the highest quartile of direct home discharge (Q4) compared with hospitals in the lowest (Q1) were more likely to use femoral access (75.2% versus 60.1%, P<0.001), had fewer patients receiving transfusion (26.4% versus 40.9%, P<0.001), and were more likely to be located in the Southern United States (48.8% versus 18.3%, P<0.001). Median 30-day readmission rate was 17.9%. There was no significant difference in 30-day readmissions among quartiles (P=0.14), even after multivariable adjustment (odds ratio Q4 versus Q1=0.89, 95%CI 0.76-1.04; P=0.15). Factors most strongly associated with 30-day readmission were glomerular filtration rate, in-hospital stroke or transient ischemic attack, and nonfemoral access. CONCLUSIONS: There was no statistically significant association between hospital practice of direct home discharge post-transcatheter aortic valve replacement and 30-day readmission. Further research is needed to understand regional variations and optimum strategies for postdischarge care.