Faculty Bibliography

OBJECTIVES: To develop and validate the Geriatric CompleXity of Care Index (GXI), a comorbidity index of medical, geriatric, and psychosocial conditions that addresses disease severity and intensity of ambulatory care for older adults with chronic conditions. DESIGN: Development phase: variable selection and rating by clinician panel. Validation phase: medical record review and secondary data analysis. SETTING: Assessing the Care of Vulnerable Elders-2 study. PARTICIPANTS: Six hundred forty-four older (>/=75) individuals receiving ambulatory care. MEASURES: Development: 32 conditions categorized according to severity, resulting in 117 GXI variables. A panel of clinicians rated each GXI variable with respect to the added difficulty of providing primary care for an individual with that condition. Validation: Modified versions of previously validated comorbidity measures (simple count, Charlson, Medicare Hierarchical Condition Category), longitudinal clinical outcomes (functional decline, survival), intensity of ambulatory care (primary, specialty care visits, polypharmacy, number of eligible quality indicators (NQI)) over 1 year of care. RESULTS: The most-morbid individuals (according to quintiles of GXI) had more visits (7.0 vs 3.7 primary care, 6.2 vs 2.4 specialist), polypharmacy (14.3% vs 0% had >/=14 medications), and greater NQI (33 vs 25) than the least-morbid individuals. Of the four comorbidity measures, the GXI was the strongest predictor of primary care visits, polypharmacy, and NQI (P < .001, controlling for age, sex, function-based vulnerability). CONCLUSION: Older adults with complex care needs, as measured by the GXI, have healthcare needs above what previously employed comorbidity measures captured. Healthcare systems could use the GXI to identify the most complex elderly adults and appropriately reimburse primary providers caring for older adults with the most complex care needs for providing additional visits and coordination of care.

BACKGROUND: Middle-aged and older adults with diabetes are heterogeneous and may be characterized as belonging to one of three clinical groups: a relatively healthy group, a group having characteristics likely to make diabetes self-management difficult, and a group with poor health status for whom current management targets have uncertain benefit. METHODS: We analyzed waves 2004-2008 of the Health and Retirement Study and the supplemental Health and Retirement Study 2003 Diabetes Study. The sample included adults with diabetes 51 years and older (n = 3,507, representing 13.6 million in 2004). We investigated the mortality outcomes for the three clinical groups, using survival analysis and Cox proportional hazard models. RESULTS: The 5-year survival probabilities were Relatively Healthy Group, 90.8%; Self-Management Difficulty Group, 79.4%; and Uncertain Benefit Group, 52.5%. For all age groups and clinical groups, except those 76 years and older in the Uncertain Benefit Group, survival exceeded 50%. CONCLUSIONS: This study reveals the substantial survival of middle-aged and older adults with diabetes, regardless of health status. These findings have implications for the clinical management of and future research about diabetes patients with multiple comorbidities.

OBJECTIVES: To determine the prevalence of cognitive impairment in older adults with heart failure (HF). DESIGN: Cross-sectional analysis of the 2004 wave of the nationally representative Health and Retirement Study linked to 2002 to 2004 Medicare administrative claims. SETTING: United States, community. PARTICIPANTS: Six thousand one hundred eighty-nine individuals aged 67 and older. MEASUREMENTS: An algorithm was developed using a combination of self- and proxy report of a heart problem and the presence of one or more Medicare claims in administrative files using standard HF diagnostic codes. On the basis of the algorithm, three categories were created to characterize the likelihood of a HF diagnosis: high or moderate probability of HF, low probability of HF, and no HF. Cognitive function was assessed using a screening measure of cognitive function or according to proxy rating. Age-adjusted prevalence estimates of cognitive impairment were calculated for the three groups. RESULTS: The prevalence of cognitive impairment consistent with dementia in older adults with HF was 15%, and the prevalence of mild cognitive impairment was 24%. The odds of dementia in those with HF were significantly higher, even after adjustment for age, education level, net worth, and prior stroke (odds ratio = 1.52, 95% confidence interval = 1.14-2.02). CONCLUSION: Cognitive impairment is common in older adults with HF and is independently associated with risk of dementia. A cognitive assessment should be routinely incorporated into HF-focused models of care.

OBJECTIVES: To determine the degree to which hyperglycemia predicts the development of frailty and lower extremity mobility limitations. DESIGN: Secondary data analysis of longitudinal data collected in a prospective cohort study. SETTING: Baltimore, Maryland. PARTICIPANTS: Three hundred twenty-nine women from the Women's Health and Aging Study II aged 70 to 79 at baseline who had all variables needed for analysis. MEASUREMENTS: Glycosylated hemoglobin (HbA1c) at baseline, categorized as less than 5.5%, 5.5% to 5.9%, 6.0% to 6.4%, 6.5% to 7.9%, and 8.0% and greater, was the independent variable. The incidence of frailty and lower extremity mobility limitations (based on self-reported walking difficulty, walking speed, and Short Performance Physical Battery score) was determined (follow-up approximately 9 years). Frailty was assessed using the Cardiovascular Health Study criteria. Covariates included demographic characteristics, body mass index, interleukin-6 level, and clinical history of comorbidities. Statistical analyses included Kaplan-Meier survival curves and Cox regression models adjusted for important covariates. RESULTS: In time-to-event analyses, HbA1c category was associated with incidence of walking difficulty (P = .049) and low physical performance (P = .001); association with incidence of frailty and low walking speed had a trend toward significance (both P = .10). In regression models adjusted for demographic characteristics, HbA1c of 8.0% or greater (vs < 5.5%) was associated with an approximately three-times greater risk of incident frailty and three to five times greater risk of lower extremity mobility limitations (all P < .05). In fully adjusted models, HbA1c of 8.0% or greater (vs < 5.5%) was associated with incident frailty (hazard ratio (HR) = 3.33, 95% confidence interval (CI) = 1.24-8.93), walking difficulty (HR = 3.47, 95% CI = 1.26-9.55), low walking speed (HR = 2.82, 95% CI = 1.19-6.71), and low physical performance (HR = 3.60, 95% CI = 1.52-8.53). CONCLUSION: Hyperglycemia is associated with the development of frailty and lower extremity mobility limitations in older women. Future studies should identify mediators of these relationships.

Ensuring the safe transition of patients from hospitals to skilled nursing facilities and from skilled nursing facilities back to the hospital or the community can present significant challenges. The University of Michigan Health System was able to overcome many of these challenges through the implementation of a health system associated Subacute Care Service that consists of the University of Michigan Health System geriatricians and nurse practitioners working in privately operated skilled nursing facilities in our primary market area. We describe the planning process surrounding the development of the Subacute Care Service and report on efforts to date.

BACKGROUND: Little research has been conducted on the predictors of self-report or patient awareness of heart failure (HF) in a population-based survey. The objective of this study was to (1) test the agreement between Medicare administrative and Health and Retirement Study (HRS) survey data and (2) determine predictors associated with self-report of HF, using a validated Medicare claims algorithm as the reference standard. We hypothesized that those who self-reported HF were more likely to have a higher number of HF-related claims. METHODS AND RESULTS: Secondary data analysis was conducted using the 2004 wave of the HRS linked to 2002 to 2004 Medicare claims (n=5573 respondents aged >/= 67 years). Concordance between self-report of HF in the HRS and Medicare claims was calculated. Logistic regression was performed to identify predictors associated with self-report HF. HF prevalence by self-report was 4.6%. Self-report of HF and claims agreement was 87% (kappa=0.34). The presence of >1 HF inpatient claims was associated with greater odds of self-report (odds ratio [OR], 1.92; 95% CI, 1.23-3.00). Greater odds of self-reporting HF was also associated with >/= 4 HF claims (OR, 2.74; 95% CI, 1.36-5.52). Blacks (OR, 0.28; 95% CI, 0.14-0.55) and Hispanics (OR, 0.30; 95% CI, 0.11-0.83) were less likely to self-report HF compared with whites in the final model. CONCLUSIONS: Self-report of HF is an insensitive method for accurately identifying HF cases, especially in those with less-severe disease and who are nonwhite. There may be limited awareness of HF among older minority patients despite having clinical encounters during which HF is coded as a diagnosis.

OBJECTIVES: To compare the safety and efficacy of adding insulin glargine or neutral protamine Hagedorn (NPH) insulin to existing oral antidiabetic drug (OAD) regimens in adults with type 2 diabetes mellitus. DESIGN: Pooled analysis of data from five randomized controlled trials with similar designs. SETTING: Three hundred forty-two centers in more than 30 countries worldwide. PARTICIPANTS: Randomly selected individuals aged /=65, n = 604 vs < 65, n = 2,091) and age based on treatment (e.g., >/=65 receiving insulin glargine vs NPH insulin). Outcomes included change in HbA1c, fasting blood glucose (FBG), insulin dose, and hypoglycemia incidence and event rates. RESULTS: At end point, participants aged 65 and older receiving insulin glargine had greater reductions in HbA1c and FBG than those receiving similar doses of NPH insulin. In contrast, for participants younger than 65, there were no statistically significant differences in reductions in HbA1c or FBG between insulin glargine and NPH insulin. Daytime hypoglycemia rates were similar in all groups, although the rates of nocturnal symptomatic and severe hypoglycemia were lower with insulin glargine than NPH insulin. CONCLUSION: Addition of insulin glargine to oral antidiabetic drugs in older adults with poor glycemic control may have modestly better glycemic benefits than adding NPH insulin, with low risk of hypoglycemia.

While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient-peers and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers, and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.

OBJECTIVE: The goals of this study were to examine trajectories of blood pressure (BP) in adults with diabetes and investigate the association of trajectory patterns with mortality. RESEARCH DESIGN AND METHODS: A nonconcurrent longitudinal design was used to monitor 3,766 Medicare patients with diabetes from 2005 through 2008. Data were extracted from a registry of Medicare beneficiaries, which was developed by a large academic practice that participated in the Physician Group Practice Medicare Demonstration. The relationship between BP trajectories and all-cause mortality was modeled using multilevel mixed-effects linear regression. RESULTS: During the 4-year study period, 10.7% of the patients died, half of whom were aged>/=75 years. The crude and adjusted models both showed a greater decline in systolic and diastolic BP in patients who died than in those who did not die. In a model adjusted for age, sex, race, medications, and comorbidities, the mean systolic BP decreased by 3.2 mmHg/year (P<0.001) in the years before death and by 0.7 mmHg/year (P<0.001) in those who did not die (P<0.001 for the difference in slopes). Similarly, diastolic BP declined by 1.3 mmHg/year for those who died (P<0.001) and by 0.6 mmHg/year for those who did not die (P<0.001); the difference in slopes was significant (P=0.021). CONCLUSIONS: Systolic and diastolic BP both declined more rapidly in the 4 years before death than in patients who remained alive.

BACKGROUND: Due to a shortage of studies focusing on older adults, clinicians and policy makers frequently rely on clinical trials of the general population to provide supportive evidence for treating complex, older patients. OBJECTIVES: To examine the inclusion and analysis of complex, older adults in randomized controlled trials. REVIEW METHODS: A PubMed search identified phase III or IV randomized controlled trials published in 2007 in JAMA, NEJM, Lancet, Circulation, and BMJ. Therapeutic interventions that assessed major morbidity or mortality in adults were included. For each study, age eligibility, average age of study population, primary and secondary outcomes, exclusion criteria, and the frequency, characteristics, and methodology of age-specific subgroup analyses were reviewed. RESULTS: Of the 109 clinical trials reviewed in full, 22 (20.2%) excluded patients above a specified age. Almost half (45.6%) of the remaining trials excluded individuals using criteria that could disproportionately impact older adults. Only one in four trials (26.6%) examined outcomes that are considered highly relevant to older adults, such as health status or quality of life. Of the 42 (38.5%) trials that performed an age-specific subgroup analysis, fewer than half examined potential confounders of differential treatment effects by age, such as comorbidities or risk of primary outcome. Trials with age-specific subgroup analyses were more likely than those without to be multicenter trials (97.6% vs. 79.1%, p < 0.01) and funded by industry (83.3% vs. 62.7%, p < 0.05). Differential benefit by age was found in seven trials (16.7%). CONCLUSION: Clinical trial evidence guiding treatment of complex, older adults could be improved by eliminating upper age limits for study inclusion, by reducing the use of eligibility criteria that disproportionately affect multimorbid older patients, by evaluating outcomes that are highly relevant to older individuals, and by encouraging adherence to recommended analytic methods for evaluating differential treatment effects by age.