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.

Introduction: Patients and families are often asked to make decisions regarding feeding tube placement during a medical crisis. The risks, benefits, and alternative treatment choices are not communicated by a standard method, and the consultants placing the tubes are often invited to join the discussion at a late stage. Our aim is to improve this process with a focus on patient and family preferences and patient safety, by educating medicine residents about feeding tubes and providing them with a shared decision making tool utilizing an electronic book (iBook). Methods: We created a one hour noon conference program for residents in which we reviewed information about enteral feeding, including types of tubes, placement methods, indications, contraindications, complications, and feeding tube use in selected medical conditions, with a focus on dementia. During this session the iBook was introduced for use in discussions with patients and families. Pre- and postintervention surveys were given to the residents to determine their knowledge and comfort level with the content. Gastroenterology fellows were also surveyed to determine if there was a difference in the nature of the feeding tube consults before and after the intervention. We used the chi-squared or Fisher's exact test to compare dichotomous outcomes in the pre- and post- intervention groups. Results: Among residents, there was a statistically significant increase in the proportion of individuals who answered that they were very comfortable/competent in all six questions regarding feeding tube placement after the intervention (p < 0.01 for all). Among fellows, there was perceived improvement in resident and patient knowledge regarding feeding tube placement as well as appropriateness of consults after the intervention, however these were not statistically significant due to the small sample size. There was a perceived decrease in the frequency of appropriate feeding tube placements after the intervention, which was also statistically non-significant. None of the residents reported that they had used the iBook with patients. Conclusion: Residents are often the first physicians to discuss feeding tube placement with patients and families in the acute inpatient setting, however many report that they are not equipped to lead this discussion. Formal education about feeding tubes improves resident comfort/competence in this area and should be incorporated into medicine housestaff curricula

OBJECTIVE:: In 2011, 15.8% of eligible patients in the United States were vaccinated against herpes zoster (HZ). To increase the usage of the HZ vaccine by studying physicians' knowledge, attitudes, practices, and perceived obstacles after interventions to overcome barriers. METHODS:: General internal medicine physicians were surveyed with a cross-sectional internet survey from October to December 2011 before interventions to increase the use of the HZ vaccine and 1 year later. Interventions included education, increasing availability at the medical center pharmacy, and electronic medical record reminders. Outcome measures included changes in knowledge, attitudes, and practices, and perceived barriers. McNemar chi-square tests were used to compare the changes from the baseline survey for physicians who completed the follow-up survey. RESULTS:: Response rate for the baseline study was 33.5% (89/266) and for the follow-up was 29.8% (75/252). Fifty-five completed both surveys. There was a decrease from 57% at baseline to 40% at follow-up in the proportion of physicians who reported that less than 10% of their patients were vaccinated. They were more likely to know the HZ annual incidence (30% baseline; 70% follow-up; P=0.02), and report having educational information for physicians (7% baseline; 27% follow-up; P=0.003). The top helpful intervention was nursing administration of the vaccine. Average monthly HZ vaccine usage in the affiliated outpatient pharmacy increased in 10 months between surveys by 156% compared with the 3 months before the baseline survey. CONCLUSIONS:: Interventions implemented during the study led to an increase in physicians' basic knowledge of the HZ vaccine and an increase in usage at the affiliated pharmacy.

PURPOSE:: To increase usage of the herpes zoster (HZ) vaccine at an academic medical center by studying physicians' knowledge, attitudes, practices, and perceived barriers and analyze the findings by practice setting. METHODS:: A cross-sectional Internet-based survey administered to all 266 general internal medicine physicians in 4 clinical settings at an academic medical center between October 6 and December 12, 2011. Outcomes measures included knowledge questions regarding the disease and vaccine recommendations, Likert-type items about physician attitudes and practices, and questions about barriers and proposed interventions to improve utilization. RESULTS:: Response rate was 33.5% (89 of 266). Responders did not answer all questions. Only 66% (42 of 64) responded that HZ vaccination was an important clinical priority, and 48% (38 of 79) reported that less than 10% of their patients received the HZ vaccine. 95% responded that the influenza (61 of 64) and 92% that the pneumococcal (59 of 64) vaccines were important. Approximately 53% (42 of 79) and 51% (40 of 78) reported that more than 75% of their patients received these vaccines, respectively. Top barrier to vaccination was cost to patients (51 of 66; 77%). Lack of awareness of national recommendations (46 of 65, 71%) varied by setting. Physicians' preferred interventions included nurse-initiated prompting about vaccination (36 of 75, 48%) and chart reminders (34 of 74, 46%). CONCLUSIONS:: Not only increased knowledge but also a change in attitudes and practice are needed to enhance implementation of national recommendations. To improve use of this vaccine, physicians including ophthalmologists need to recommend it more strongly.