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Schubert CC, Penney LS, Schwartzkopf AL, Damush TM, Preddie A, Flemming S, Myers J, Myers LJ, Perkins AJ, Zhang Y, Bravata DM. Expanding Access to Comprehensive Geriatric Evaluation via Telehealth: Development of Hybrid-Virtual Home Visits. J Gen Intern Med 2024; 39:36-43. [PMID: 38227169 PMCID: PMC10937878 DOI: 10.1007/s11606-023-08460-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/06/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND In response to the aging population, the Department of Veterans Affairs (VA) seeks to expand access to evidence-based practices which support community-dwelling older persons such as the Geriatric Resources for Assessment and Care of Elders (GRACE) program. GRACE is a multidisciplinary care model which provides home-based geriatric evaluation and management for older Veterans residing within a 20-mile drive radius from the hospital. We sought to expand the geographic reach of VA-GRACE by developing a hybrid-virtual home visit (TeleGRACE). OBJECTIVES The objectives were to: (1) describe challenges encountered and solutions implemented during the iterative, pre-implementation program development process; and (2) illustrate potential successes of the program with two case examples. DESIGN Quality improvement project with longitudinal qualitative data collection. PROGRAM DESCRIPTION The hybrid-virtual home visit involved a telehealth technician travelling to patients' homes and connecting virtually to VA-GRACE team members who participated remotely. APPROACH & PARTICIPANTS We collected multiple data streams throughout program development: TeleGRACE staff periodic reflections, fieldnotes, and team meeting notes; and VA-GRACE team member interviews. KEY RESULTS The five program domains that required attention and problem-solving were: telehealth connectivity and equipment, virtual physical examination, protocols and procedures, staff training, and team integration. For each domain, we describe several challenges and solutions. An example from the virtual physical examination domain: several iterations were required to identify the combination of telehealth stethoscope with dedicated headphones that allowed remote nurse practitioners to hear heart and lung sounds. The two cases illustrate how this hybrid-virtual home visit model provided care for patients who would not otherwise have received timely healthcare services. CONCLUSIONS These results provide a blueprint to translate an in-person home-based geriatrics program into a hybrid-virtual model and support the feasibility of using hybrid-virtual home visits to expand access to comprehensive geriatric evaluation and ongoing care for high-risk, community-dwelling older persons who reside geographically distant from the primary VA facility.
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Affiliation(s)
- Cathy C Schubert
- Geriatrics and Community Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lauren S Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Ashley L Schwartzkopf
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Teresa M Damush
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Alaina Preddie
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Soyna Flemming
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Jennifer Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dawn M Bravata
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA.
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
- Regenstrief Institute, Indianapolis, IN, USA.
- Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis, IN, USA.
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Boockvar KS, Koufacos NS, May J, Schwartzkopf AL, Guerrero VM, Judon KM, Schubert CC, Franzosa E, Dixon BE. Effect of Health Information Exchange Plus a Care Transitions Intervention on Post-Hospital Outcomes Among VA Primary Care Patients: a Randomized Clinical Trial. J Gen Intern Med 2022; 37:4054-4061. [PMID: 35199262 PMCID: PMC9708976 DOI: 10.1007/s11606-022-07397-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/04/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Health information exchange (HIE) notifications when patients experience cross-system acute care encounters offer an opportunity to provide timely transitions interventions to improve care across systems. OBJECTIVE To compare HIE notification followed by a post-hospital care transitions intervention (CTI) with HIE notification alone. DESIGN Cluster-randomized controlled trial with group assignment by primary care team. PATIENTS Veterans 65 or older who received primary care at 2 VA facilities who consented to HIE and had a non-VA hospital admission or emergency department visit between 2016 and 2019. INTERVENTIONS For all subjects, real-time HIE notification of the non-VA acute care encounter was sent to the VA primary care provider. Subjects assigned to HIE plus CTI received home visits and telephone calls from a VA social worker for 30 days after arrival home, focused on patient activation, medication and condition knowledge, patient-centered record-keeping, and follow-up. MEASURES Primary outcome: 90-day hospital admission or readmission. SECONDARY OUTCOMES emergency department visits, timely VA primary care team telephone and in-person follow-up, patients' understanding of their condition(s) and medication(s) using the Care Transitions Measure, and high-risk medication discrepancies. KEY RESULTS A total of 347 non-VA acute care encounters were included and assigned: 159 to HIE plus CTI and 188 to HIE alone. Veterans were 76.9 years old on average, 98.5% male, 67.8% White, 17.1% Black, and 15.1% other (including Hispanic). There was no difference in 90-day hospital admission or readmission between the HIE-plus-CTI and HIE-alone groups (25.8% vs. 20.2%, respectively; risk diff 5.6%; 95% CI - 3.3 to 14.5%, p = .25). There was also no difference in secondary outcomes. CONCLUSIONS A care transitions intervention did not improve outcomes for veterans after a non-VA acute care encounter, as compared with HIE notification alone. Additional research is warranted to identify transitions services across systems that are implementable and could improve outcomes.
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Affiliation(s)
- Kenneth S Boockvar
- James J. Peters VA Medical Center, Geriatrics Research Education & Clinical Center, Bronx, NY, 10468, USA.
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- The New Jewish Home, New York, NY, USA.
| | - Nicholas S Koufacos
- James J. Peters VA Medical Center, Geriatrics Research Education & Clinical Center, Bronx, NY, 10468, USA
| | - Justine May
- Richard L. Roudebush VA Medical Center, Center for Health Information and Communication, Indianapolis, IN, USA
| | - Ashley L Schwartzkopf
- Richard L. Roudebush VA Medical Center, Center for Health Information and Communication, Indianapolis, IN, USA
| | - Vivian M Guerrero
- James J. Peters VA Medical Center, Geriatrics Research Education & Clinical Center, Bronx, NY, 10468, USA
| | - Kimberly M Judon
- James J. Peters VA Medical Center, Geriatrics Research Education & Clinical Center, Bronx, NY, 10468, USA
| | - Cathy C Schubert
- Richard L. Roudebush VA Medical Center, Center for Health Information and Communication, Indianapolis, IN, USA
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Emily Franzosa
- James J. Peters VA Medical Center, Geriatrics Research Education & Clinical Center, Bronx, NY, 10468, USA
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian E Dixon
- Richard L. Roudebush VA Medical Center, Center for Health Information and Communication, Indianapolis, IN, USA
- Department of Epidemiology, Indiana University Fairbanks School of Public Health, Indianapolis, IN, USA
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, USA
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Schubert CC, Perkins AJ, Myers LJ, Damush TM, Penney LS, Zhang Y, Schwartzkopf AL, Preddie AK, Riley S, Menen T, Bravata DM. Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program: An observational cohort study. J Am Geriatr Soc 2022; 70:3598-3609. [PMID: 36054760 PMCID: PMC10087268 DOI: 10.1111/jgs.18013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/01/2022] [Accepted: 07/29/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND As the Department of Veterans Affairs (VA) healthcare system seeks to expand access to comprehensive geriatric assessments, evidence-based models of care are needed to support community-dwelling older persons. We evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction. METHODS This retrospective cohort included patients admitted to the Richard L. Roudebush VA hospital (2010-2019) who received VA-GRACE services post-discharge and usual care controls who were potentially eligible for VA-GRACE but did not receive services. The VA-GRACE program provided home-based comprehensive, multi-disciplinary geriatrics assessment, and ongoing care. Primary outcomes included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and staff satisfaction. We used propensity score modeling with overlapping weighting to adjust for differences in characteristics between groups. RESULTS VA-GRACE patients (N = 683) were older than controls (N = 4313) (mean age 78.3 ± 8.2 standard deviation vs. 72.2 ± 6.9 years; p < 0.001) and had greater comorbidity (median Charlson Comorbidity Index 3 vs. 0; p < 0.001). VA-GRACE patients had higher 90-day readmissions (adjusted odds ratio [aOR] 1.55 [95%CI 1.01-2.38]) and higher 1-year readmissions (aOR 1.74 [95%CI 1.22-2.48]). However, VA-GRACE patients had lower 90-day mortality (aOR 0.31 [95%CI 0.11-0.92]), but no statistically significant difference in 1-year mortality was observed (aOR 0.88 [95%CI 0.55-1.41]). Patients and caregivers reported that VA-GRACE home visits reduced travel burden and the program linked Veterans and caregivers to needed resources. Primary care providers reported that the VA-GRACE team helped to reduce their workload, improved medication management for their patients, and provided a view into patients' daily living situation. CONCLUSIONS The VA-GRACE program provides comprehensive geriatric assessments and care to high-risk, community-dwelling older persons with high rates of satisfaction from patients, caregivers, and providers. Widespread deployment of programs like VA-GRACE will be required to support Veterans aging in place.
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Affiliation(s)
- Cathy C. Schubert
- Medicine ServiceRichard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Anthony J. Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- Department of BiostatisticsIndiana University School of Medicine, IUPUIIndianapolisIndianaUSA
| | - Laura J. Myers
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Teresa M. Damush
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Regenstrief InstituteIndianapolisIndianaUSA
| | - Lauren S. Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care SystemSan AntonioTexasUSA
- Department of MedicineUniversity of Texas Health San AntonioSan AntonioTexasUSA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- Department of BiostatisticsCollege of Public Health, University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Ashley L. Schwartzkopf
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Alaina K. Preddie
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Sam Riley
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Tetla Menen
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Dawn M. Bravata
- Medicine ServiceRichard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Regenstrief InstituteIndianapolisIndianaUSA
- Department of NeurologyIndiana University School of MedicineIndianapolisIndianaUSA
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Koufacos NS, May J, Judon KM, Franzosa E, Dixon BE, Schubert CC, Schwartzkopf AL, Guerrero VM, Traylor M, Boockvar KS. Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention. J Gerontol Soc Work 2022; 65:63-77. [PMID: 34053407 PMCID: PMC8982469 DOI: 10.1080/01634372.2021.1932003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 06/12/2023]
Abstract
Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.
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Affiliation(s)
- Nicholas S Koufacos
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Justine May
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Kimberly M Judon
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Emily Franzosa
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian E Dixon
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
- Department of Epidemiology, Indiana University, Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Center for Biomedical Informatics, Regenstrief Institute, Center for Biomedical Informatics, Indianapolis, Indiana, USA
| | - Cathy C Schubert
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University, School of Medicine, Indianapolis, Indiana, USA
| | - Ashley L Schwartzkopf
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Vivian M Guerrero
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Morgan Traylor
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Kenneth S Boockvar
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Dixon BE, Judon KM, Schwartzkopf AL, Guerrero VM, Koufacos NS, May J, Schubert CC, Boockvar KS. Impact of event notification services on timely follow-up and rehospitalization among primary care patients at two Veterans Affairs Medical Centers. J Am Med Inform Assoc 2021; 28:2593-2600. [PMID: 34597411 DOI: 10.1093/jamia/ocab189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To examine the effectiveness of event notification service (ENS) alerts on health care delivery processes and outcomes for older adults. MATERIALS AND METHODS We deployed ENS alerts in 2 Veterans Affairs (VA) medical centers using regional health information exchange (HIE) networks from March 2016 to December 2019. Alerts targeted VA-based primary care teams when older patients (aged 65+ years) were hospitalized or attended emergency departments (ED) outside the VA system. We employed a concurrent cohort study to compare postdischarge outcomes between patients whose providers received ENS alerts and those that did not (usual care). Outcome measures included: timely follow-up postdischarge (actual phone call within 7 days or an in-person primary care visit within 30 days) and all-cause inpatient or ED readmission within 30 days. Generalized linear mixed models, accounting for clustering by primary care team, were used to compare outcomes between groups. RESULTS Compared to usual care, veterans whose primary care team received notification of non-VA acute care encounters were 4 times more likely to have phone contact within 7 days (AOR = 4.10, P < .001) and 2 times more likely to have an in-person visit within 30 days (AOR = 1.98, P = .007). There were no significant differences between groups in hospital or ED utilization within 30 days of index discharge (P = .057). DISCUSSION ENS was associated with increased timely follow-up following non-VA acute care events, but there was no associated change in 30-day readmission rates. Optimization of ENS processes may be required to scale use and impact across health systems. CONCLUSION Given the importance of ENS to the VA and other health systems, this study provides guidance for future research on ENS for improving care coordination and population outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT02689076. "Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization." Registered February 23, 2016.
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Affiliation(s)
- Brian E Dixon
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA.,Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Kimberly M Judon
- Department of Veterans Affairs, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Ashley L Schwartzkopf
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - Vivian M Guerrero
- Department of Veterans Affairs, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Nicholas S Koufacos
- Department of Veterans Affairs, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Justine May
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - Cathy C Schubert
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA.,Division of Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kenneth S Boockvar
- Department of Veterans Affairs, James J. Peters VA Medical Center, Bronx, New York, USA.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Affiliation(s)
- Cathy C Schubert
- Indiana University School of Medicine and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana (C.C.S.)
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Dixon BE, Schwartzkopf AL, Guerrero VM, May J, Koufacos NS, Bean AM, Penrod JD, Schubert CC, Boockvar KS. Regional data exchange to improve care for veterans after non-VA hospitalization: a randomized controlled trial. BMC Med Inform Decis Mak 2019; 19:125. [PMID: 31272427 PMCID: PMC6611045 DOI: 10.1186/s12911-019-0849-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/24/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Coordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications. METHODS In a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation. DISCUSSION While HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care. TRIAL REGISTRATION ClinicalTrials.gov NCT02689076. "Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization." Registered 23 February 2016.
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Affiliation(s)
- Brian E. Dixon
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, 1481 W. 10th St, 11H, Indianapolis, IN 46202 USA
- Indiana University, Fairbanks School of Public Health, 1050 Wishard Blvd, Indianapolis, IN 46202 USA
- Regenstrief Institute, Center for Biomedical Informatics, 1101 W 10th St, Indianapolis, IN 46202 USA
| | - Ashley L. Schwartzkopf
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, 1481 W. 10th St, 11H, Indianapolis, IN 46202 USA
| | - Vivian M. Guerrero
- Department of Veterans Affairs, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 USA
| | - Justine May
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, 1481 W. 10th St, 11H, Indianapolis, IN 46202 USA
| | - Nicholas S. Koufacos
- Department of Veterans Affairs, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 USA
| | - Andrew M. Bean
- Department of Veterans Affairs, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 USA
| | - Joan D. Penrod
- Department of Veterans Affairs, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 USA
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - Cathy C. Schubert
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, 1481 W. 10th St, 11H, Indianapolis, IN 46202 USA
- Indiana University, School of Medicine, 1101 W. 10th St, Indianapolis, IN 46202 USA
| | - Kenneth S. Boockvar
- Department of Veterans Affairs, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 USA
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
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Schubert CC, Parks R, Coffing JM, Daggy J, Slaven JE, Weiner M. Lessons and Outcomes of Mobile Acute Care for Elders Consultation in a Veterans Affairs Medical Center. J Am Geriatr Soc 2018; 67:818-824. [PMID: 30575012 DOI: 10.1111/jgs.15730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/16/2018] [Accepted: 11/17/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Describe the implementation and effects of Mobile Acute Care for Elders (MACE) consultation at a Veterans Affairs Medical Center (VAMC). DESIGN Retrospective cohort analysis. INTERVENTION Veterans aged 65 or older who were admitted to the medicine service between October 1, 2012, and September 30, 2014, were screened for geriatric syndromes via review of medical records within 48 hours of admission. If the screen was positive, the MACE team offered the admitting team a same-day consultation involving comprehensive geriatric assessment and ongoing collaboration with the admitting team and supportive services to implement patient-centric recommendations for geriatric syndromes. RESULTS Veterans seen by MACE (n = 421) were compared with those with positive screens but without consultation (n = 372). The two groups did not significantly differ in age, comorbidity, sex, or race. All outcomes (30-day readmission, 30-day mortality, readmission costs) were in the expected direction for patients receiving MACE but did not reach statistical significance. Patients receiving MACE had lower odds of 30-day readmission (11.9% vs 14.8%; odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.54-1.25; p = .360) and 30-day mortality (5.5% vs 8.6%; OR = 0.64; CI = 0.36-1.12; p = .115), and they had lower 30-day readmission costs (MACE $15,502; CI = $12,242-$19,631; comparison = $18,335; CI = $14,641-$22,962; p = .316) than those who did not receive MACE after adjusting for age and Charlson Comorbidity Index. CONCLUSION Our MACE consultation model for older veterans with geriatric syndromes leverages the limited supply of clinicians with expertise in geriatrics. Although not statistically significant in this study of 793 subjects, MACE patients had lower odds of 30-day readmission and mortality, and lower readmission costs. J Am Geriatr Soc 67:818-824, 2019.
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Affiliation(s)
- Cathy C Schubert
- Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Rebecca Parks
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Jessica M Coffing
- Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana
| | - Joanne Daggy
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael Weiner
- Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana
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Quist KK, Counsell SR, Schubert CC, Weiner M. Medication management interventions in patients enrolled in GRACE Team Care. Geriatr Nurs 2016; 37:371-375. [DOI: 10.1016/j.gerinurse.2016.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/05/2016] [Accepted: 05/07/2016] [Indexed: 11/28/2022]
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Schubert CC, Myers LJ, Allen K, Counsell SR. Implementing Geriatric Resources for Assessment and Care of Elders Team Care in a Veterans Affairs Medical Center: Lessons Learned and Effects Observed. J Am Geriatr Soc 2016; 64:1503-9. [DOI: 10.1111/jgs.14179] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Cathy C. Schubert
- School of Medicine; Indiana University; Indianapolis Indiana
- Roudebush Veterans Affairs Medical Center; Department of Veterans Affairs; Indianapolis Indiana
| | - Laura J. Myers
- School of Medicine; Indiana University; Indianapolis Indiana
- Health Services Research and Development Center for Health Information and Communication; Indianapolis Indiana
| | - Katie Allen
- Regenstrief Institute, Inc.; Indianapolis Indiana
| | - Steven R. Counsell
- School of Medicine; Indiana University; Indianapolis Indiana
- Roudebush Veterans Affairs Medical Center; Department of Veterans Affairs; Indianapolis Indiana
- Regenstrief Institute, Inc.; Indianapolis Indiana
- Center for Aging Research; Indiana University; Indianapolis Indiana
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Schubert CC. What adoption gave me. Ann Intern Med 2015; 163:803-4. [PMID: 26571243 DOI: 10.7326/m15-1225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Affiliation(s)
- Christopher M Callahan
- Indiana University Center for Aging Research, 410 West 10th Street, Suite 2000, Indianapolis, IN 46202, USA
| | - Cathy C Schubert
- Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Code 111, Indianapolis, IN 46202, USA
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Boustani MA, Sachs GA, Alder CA, Munger S, Schubert CC, Guerriero Austrom M, Hake A, Unverzagt FW, Farlow M, Matthews BR, Perkins AJ, Beck RA, Callahan CM. Implementing innovative models of dementia care: The Healthy Aging Brain Center. Aging Ment Health 2011; 15:13-22. [PMID: 21271387 PMCID: PMC3077086 DOI: 10.1080/13607863.2010.496445] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Recent randomized controlled trials have demonstrated the effectiveness of the collaborative dementia care model targeting both the patients suffering from dementia and their informal caregivers. OBJECTIVE To implement a sustainable collaborative dementia care program in a public health care system in Indianapolis. METHODS We used the framework of Complex Adaptive System and the tool of the Reflective Adaptive Process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC). RESULTS Within its first year of operation, the HABC delivered 528 visits to serve 208 patients and 176 informal caregivers. The mean age of HABC patients was 73.8 (standard deviation, SD 9.5), 40% were African-Americans, 42% had less than high school education, 14% had normal cognitive status, 39% received a diagnosis of mild cognitive impairment, and 46% were diagnosed with dementia. Within 12 months of the initial HABC visit, 28% of patients had at least one visit to an emergency room (ER) and 14% were hospitalized with a mean length of stay of five days. The rate of a one-week ER revisit was 14% and the 30-day rehospitalization rate was 11%. Only 5% of HABC patients received an order for neuroleptics and only 16% had simultaneous orders for both definite anticholinergic and anti-dementia drugs. CONCLUSION The tools of 'implementation science' can be utilized to translate a health care delivery model developed in the research laboratory to a practical, operational, health care delivery program.
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Affiliation(s)
- Malaz A. Boustani
- Indiana University Center for Aging Research, Indianapolis, IN,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN,Regenstrief Institute, Inc., Indianapolis, IN,Indiana Alzheimer Disease Center, Indianapolis, IN, USA
| | - Greg A. Sachs
- Indiana University Center for Aging Research, Indianapolis, IN,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN,Regenstrief Institute, Inc., Indianapolis, IN,Indiana Alzheimer Disease Center, Indianapolis, IN, USA
| | - Catherine A. Alder
- Indiana University Center for Aging Research, Indianapolis, IN,Regenstrief Institute, Inc., Indianapolis, IN,Wishard Health Services, Indianapolis, IN
| | - Stephanie Munger
- Indiana University Center for Aging Research, Indianapolis, IN,Regenstrief Institute, Inc., Indianapolis, IN
| | - Cathy C. Schubert
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Mary Guerriero Austrom
- Department of Psychiatry; Indiana University School of Medicine, Indianapolis, IN,Indiana Alzheimer Disease Center, Indianapolis, IN, USA
| | - Ann Hake
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN,Indiana Alzheimer Disease Center, Indianapolis, IN, USA
| | - Frederick W. Unverzagt
- Department of Psychiatry; Indiana University School of Medicine, Indianapolis, IN,Indiana Alzheimer Disease Center, Indianapolis, IN, USA
| | - Martin Farlow
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN,Indiana Alzheimer Disease Center, Indianapolis, IN, USA
| | - Brandy R. Matthews
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN,Indiana Alzheimer Disease Center, Indianapolis, IN, USA
| | - Anthony J. Perkins
- Indiana University Center for Aging Research, Indianapolis, IN,Regenstrief Institute, Inc., Indianapolis, IN
| | - Robin A. Beck
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Christopher M. Callahan
- Indiana University Center for Aging Research, Indianapolis, IN,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN,Regenstrief Institute, Inc., Indianapolis, IN
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Campbell N, Boustani M, Limbil T, Ott C, Fox C, Maidment I, Schubert CC, Munger S, Fick D, Miller D, Gulati R. The cognitive impact of anticholinergics: a clinical review. Clin Interv Aging 2009; 4:225-33. [PMID: 19554093 PMCID: PMC2697587 DOI: 10.2147/cia.s5358] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Indexed: 01/15/2023] Open
Abstract
Context: The cognitive side effects of medications with anticholinergic activity have been documented among older adults in a variety of clinical settings. However, there has been no systematic confirmation that acute or chronic prescribing of such medications lead to transient or permanent adverse cognitive outcomes. Objective: Evaluate the existing evidence regarding the effects of anticholinergic medications on cognition in older adults. Data sources: We searched the MEDLINE, OVID, and CINAHL databases from January, 1966 to January, 2008 for eligible studies. Study selection: Studies were included if the anticholinergic activity was systematically measured and correlated with standard measurements of cognitive performance. Studies were excluded if they reported case studies, case series, editorials, and review articles. Data extraction: We extracted the method used to determine anticholinergic activity of medications and its association with cognitive outcomes. Results: Twenty-seven studies met our inclusion criteria. Serum anticholinergic assay was the main method used to determine anticholinergic activity. All but two studies found an association between the anticholinergic activity of medications and either delirium, cognitive impairment or dementia. Conclusions: Medications with anticholinergic activity negatively affect the cognitive performance of older adults. Recognizing the anticholinergic activity of certain medications may represent a potential tool to improve cognition.
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Westmoreland GR, Counsell SR, Sennour Y, Schubert CC, Frank KI, Wu J, Frankel RM, Litzelman DK, Bogdewic SP, Inui TS. Improving medical student attitudes toward older patients through a "council of elders" and reflective writing experience. J Am Geriatr Soc 2009; 57:315-20. [PMID: 19207146 DOI: 10.1111/j.1532-5415.2008.02102.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In an effort to reduce "agism" which is prevalent among medical trainees, a new geriatrics educational experience for medical students aimed at improving attitudes toward older patients was developed. Each 90-minute Older Adult Session included four components: initial reflective writing exercise; introduction to the session; 75-minute dialogue with the "Council of Elders," a group of active, "well" older adults; and final reflective writing exercise. The new session was provided to 237 first- and second-year medical students during the 2006/07 academic year at Indiana University School of Medicine. Session evaluation included comparing scores on the 14-item Geriatrics Attitude Scale administered before and after the session, identifying attitude changes in the reflective writing exercises, and a student satisfaction survey. Student responses on the Geriatrics Attitude Scale after the session were significantly improved in seven of 14 items, demonstrating better attitudes toward being with and listening to older people and caring for older patients. Analysis of the reflective writings revealed changing of negative to positive or reinforced positive attitudes in 27% of medical students, with attitudes not discernable in the remaining 73% (except one student, in whom positive attitudes changed to negative). Learner satisfaction with the Older Adult Session was high, with 98% agreeing that the session had a positive effect on insight into the care of older adults. A Council of Elders coupled with a reflective writing exercise is a promising new approach to improving attitudes of medical students toward their geriatric patients.
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Schubert CC, Boustani M, Callahan CM, Perkins AJ, Hui S, Hendrie HC. Acute care utilization by dementia caregivers within urban primary care practices. J Gen Intern Med 2008; 23:1736-40. [PMID: 18690489 PMCID: PMC2585674 DOI: 10.1007/s11606-008-0711-0] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Revised: 02/05/2008] [Accepted: 06/17/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND Caring for an individual with Alzheimer's dementia (AD) is stressful, and studies show that this stress has an impact on both the physical and mental health of the caregiver. However, many questions remain about the characteristics of AD patients and their caregivers that contribute to this stress and how it impacts caregivers' use of healthcare resources. OBJECTIVE To study the impact of stress on the physical and mental health of the caregiver. DESIGN Patients underwent extensive testing to allow description of their degree of cognitive impairment, behavioral and psychological symptoms, medical comorbidities, and functional abilities. Caregivers were assessed for depressive symptoms and also for emergency department (ED) use and hospitalizations in the previous six months. Multivariate logistic regression was used to evaluate impact of patients' dementia symptoms on caregivers' acute care utilization. PARTICIPANTS One hundred and fifty-three AD patients and their caregivers attending two large, urban, university-affiliated primary care practices were enrolled in a cross-sectional study to examine the facets of dementia caregiving that impact caregiver acute health care utilization. RESULTS Twenty-four percent of the caregivers had at least one ED visit or hospitalization in the six months prior to enrollment. After adjusting for caregiver age, gender, and education, our logistic regression model found that the caregivers' acute care utilization was associated with their depression as measured by the PHQ-9 (OR 1.09, 95% CI 1.00-1.18), the patients' behavioral and psychological symptoms as measured by the NPI (OR 1.04, 95% CI 1.01-1.08), and the patients' functional status as measured by the ADCS-ADL (OR 1.05, 95% CI 1.01-1.09). CONCLUSION To improve the health of AD caregivers, a primary care system needs to reallocate resources to manage the functional, behavioral, and psychological symptoms related to the care-recipients suffering from AD.
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Affiliation(s)
- Cathy C Schubert
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Schubert CC, Gross C, Hurria A. Functional assessment of the older patient with cancer. Oncology (Williston Park) 2008; 22:916-928. [PMID: 18709902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Cancer is a disease associated with aging. As the population ages worldwide, the number of older adults with cancer is dramatically increasing. In both the geriatric and oncology literature, an individual's functional status is one of the strongest predictors of overall survival and resource requirement. However, the measures traditionally used in oncology practice to assess functional status in patients of all ages--and to determine the course of treatment--do not identify the subtle degrees of functional impairment that predict morbidity and mortality in the geriatric population. This article describes the tools used by geriatricians to assess physical function, and outlines their prognostic significance for the patient with cancer. Including these tools in daily oncology practice could help physicians to better assess and treat vulnerable older adults.
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Affiliation(s)
- Cathy C Schubert
- Department of Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Schubert CC, Boustani M, Callahan CM, Perkins AJ, Carney CP, Fox C, Unverzagt F, Hui S, Hendrie HC. Comorbidity profile of dementia patients in primary care: are they sicker? J Am Geriatr Soc 2006; 54:104-9. [PMID: 16420205 DOI: 10.1111/j.1532-5415.2005.00543.x] [Citation(s) in RCA: 198] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare the medical comorbidity of older patients with and without dementia in primary care. DESIGN Cross-sectional study. SETTING Wishard Health Services, which includes a university-affiliated, urban public hospital and seven community-based primary care practice centers in Indianapolis. PARTICIPANTS Three thousand thirteen patients aged 65 and older attending seven primary care centers in Indianapolis, Indiana. MEASUREMENTS An expert panel diagnosed dementia using International Classification of Diseases, 10th Revision, criteria. Comorbidity was assessed using 10 physician-diagnosed chronic comorbid conditions and the Chronic Disease Score (CDS). RESULTS Patients with dementia attending primary care have on average 2.4 chronic conditions and receive 5.1 medications. Approximately 50% of dementia patients in this setting are exposed to at least one anticholinergic medication, and 20% are prescribed at least one psychotropic medication. After adjusting for patients' age, race, and sex, patients with and without dementia have a similar level of comorbidity (mean number of chronic medical conditions, 2.4 vs 2.3, P=.66; average CDS, 5.8 vs 6.2, P=.83). CONCLUSION Multiple medical comorbid conditions are common in older adults with and without dementia in primary care. Despite their cholinergic deficit, a substantial proportion of patients with dementia are exposed to anticholinergic medications. Models of care that incorporate this medical complexity are needed to improve the treatment of dementia in primary care.
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Affiliation(s)
- Cathy C Schubert
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Rohrer MD, Schubert CC. The cutting-grinding technique for histologic preparation of undecalcified bone and bone-anchored implants. Improvements in instrumentation and procedures. Oral Surg Oral Med Oral Pathol 1992; 74:73-8. [PMID: 1324458 DOI: 10.1016/0030-4220(92)90218-f] [Citation(s) in RCA: 123] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
An improved technique for histologic sectioning of hard tissues is described. Thin sections (5 to 15 microns) of undecalcified tissues such as bones with ceramic and metallic implants as well as teeth with enamel and fillings can be produced. Implant-tissue and hard tissue-soft tissue interfaces are well preserved. Because of the development of equipment and materials designed specifically for this technique, consistently good results are obtained. Most stains used in the paraffin technique may also be used in these sections.
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Affiliation(s)
- M D Rohrer
- College of Dentistry, University of Oklahoma Health Sciences Center, Oklahoma City
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