The development of academic geriatric medicine in the United States 2005 to 2010: an essential resource for improving the medical care of older adults

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article updates the progress made by U.S. medical schools from 2005 to 2010 in developing these programs. Academic leaders in geriatrics in accredited allopathic and osteopathic medical schools were surveyed in the winter of 2010 (60% response rate), and results were compared with findings from a similar 2005 survey (68% response rate). Physician faculty in geriatrics increased from 9.6 (mean) full-time equivalents (FTEs) in 2005 to 11.2 by 2010. In 2010, faculty and staff effort was mostly devoted to clinical practice (mean = 37%) and education (mean = 33%), with only seven responding schools devoting more than 40% of faculty effort to research. Schools that have been designated as Centers of Excellence had a median 20 FTE physician faculty, compared with seven at the other schools (P < .001). In 2010, 27% of medical schools required a geriatrics clerkship, and 87% (n = 83) had an elective geriatric clerkship. In summary, more fellows and faculty were recruited and trained in 2010 than in 2005, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, but few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. New approaches to training the entire physician workforce to care for older adults will be required to ensure adequate medical care for aging Americans.

Occupational exposure to trichloroethylene and cancer risk for workers at the Paducah Gaseous Diffusion Plant

OBJECTIVE

The Paducah Gaseous Diffusion Plant (PGDP) became operational in 1952; it is located in the western part of Kentucky. We conducted a mortality study for adverse health effects that workers may have suffered while working at the plant, including exposures to chemicals.

MATERIALS AND METHODS

We studied a cohort of 6820 workers at the PGDP for the period 1953 to 2003; there were a total of 1672 deaths to cohort members. Trichloroethylene (TCE) is a specific concern for this workforce; exposure to TCE occurred primarily in departments that clean the process equipment. The Life Table Analysis System (LTAS) program developed by NIOSH was used to calculate the standardized mortality ratios for the worker cohort and standardized rate ratio relative to exposure to TCE (the U.S. population is the referent for ageadjustment). LTAS calculated a significantly low overall SMR for these workers of 0.76 (95% CI: 0.72-0.79). A further review of three major cancers of interest to Kentucky produced significantly low SMR for trachea, bronchus, lung cancer (0.75, 95% CI: 0.72-0.79) and high SMR for Non-Hodgkin's lymphoma (NHL) (1.49, 95% CI: 1.02-2.10).

RESULTS

No significant SMR was observed for leukemia and no significant SRRs were observed for any disease. Both the leukemia and lung cancer results were examined and determined to reflect regional mortality patterns. However, the Non-Hodgkin's Lymphoma finding suggests a curious amplification when living cases are included with the mortality experience.

CONCLUSIONS

Further examination is recommended of this recurrent finding from all three U.S. Gaseous Diffusion plants.

Geriatrics education in psychiatric residencies: a national survey of program directors

OBJECTIVE

The authors describe the current characteristics of geriatrics training within general psychiatry training programs.

METHODS

In the fall of 2006, a survey was mailed and made available online to all U.S. psychiatric residency program directors (N=181).

RESULTS

The response rate was 54% (n=97). Of the responding psychiatry programs, 96% (n=93) required a clinical experience in geriatrics, with a mean of 54.9 half days of required clinical training. The predominant training sites were inpatient geriatric psychiatry acute care units, ambulatory care experiences precepted by one or more geriatric psychiatrists, and outpatient geriatric psychiatry assessment centers. The mean number of physician faculty per residency program available to teach geriatrics was 2.8 full-time equivalents, and the mean number of physicians certified in geriatric psychiatry was 3.2 per program. Conflicting time demands with other curricula was ranked as the most significant barrier to expanding geriatrics training.

CONCLUSION

Variability in the amount of time devoted to geriatrics training exists across general psychiatric residency programs. Some residents spend very little time in specific required geriatric psychiatry clinical experiences and have limited exposure to well-trained geriatric psychiatrists. Therefore, some psychiatrists who will take care of older patients in the future may be ill prepared to do so.

Estimation of radon exposures to workers at the Fernald Feed Materials Production Center 1952-1988

The Feed Materials Production Center (FMPC) at Fernald, Ohio produced uranium metal products for use in Department of Energy defense programs. Radium-contaminated waste material was stored on-site in two K-65 silos on the west side of the facility and provided a source of 222Ra. The initial objective of this study was to estimate radon exposures to employees at FMPC working from 1952 to 1988. A modified Gaussian plume model was used to estimate exposures to workers. In an effort to validate these model-based estimates, we used 138 CR-39 film assays from window glass sampled in buildings throughout the site. Results from the CR-39 assays indicated a second substantial source of radon, the smaller Q-11 silos located in the production area. A response-surface regression analysis using a cubic spline model was fit to the CR-39 data to estimate 210Po surface activity levels at geographic coordinates throughout the facility. Knowledge of the age of the glass, the amount of contaminated waste in the Q-11 silos, and 210Po decay rates were used to estimate annual exposures to radon decay products (WLM: working level months). Estimated WLM levels associated with the Q-11 source term indicated that employees working in the vicinity during the period when they were filled with radium-contaminated waste (1952-1958) received substantially higher radon exposures than those from the K-65 source during this period. Results of the two models, corresponding to the K-65 and Q-11 sources, were combined to estimate WLM levels by year for each of the 7143 Fernald workers during the period 1952-1988. Estimated cumulative exposures to individual workers ranged from <0.5 to 751 WLM. Estimated radon exposures from this newly discovered source have important implications for future epidemiologic studies of lung cancer in workers at the Fernald facility.

Application of a decision support tool for anticoagulation in patients with non-valvular atrial fibrillation

BACKGROUND

Atrial fibrillation affects more than two million Americans and results in a fivefold increased rate of embolic strokes. The efficacy of adjusted dose warfarin is well documented, yet many patients are not receiving treatment consistent with guidelines. The use of a patient-specific computerized decision support tool may aid in closing the knowledge gap regarding the best treatment for a patient.

METHODS

This retrospective, observational cohort analysis of 6,123 Ohio Medicaid patients used a patient-specific computerized decision support tool that automated the complex risk-benefit analysis for anticoagulation. Adverse outcomes included acute stroke, major gastrointestinal bleeding, and intracranial hemorrhage. Cox proportional hazards models were developed to compare the group of patients who received warfarin treatment with those who did not receive warfarin treatment, stratified by the decision support tool's recommendation.

RESULTS

Our decision support tool recommended warfarin for 3,008 patients (49%); however, only 9.9% received warfarin. In patients for whom anticoagulation was recommended by the decision support tool, there was a trend towards a decreased hazard for stroke with actual warfarin treatment (hazard ratio 0.90) without significant increase in gastrointestinal hemorrhage (0.87). In contrast, in patients for whom the tool recommended no anticoagulation, receipt of warfarin was associated with statistically significant increased hazard of gastrointestinal bleeding (1.54, p = 0.03).

CONCLUSIONS

We have shown that our atrial fibrillation decision support tool is a useful predictor of those at risk of major bleeding for whom anticoagulation may not necessarily be beneficial. It may aid in weighing the benefits versus risks of anticoagulation treatment.

The development of academic geriatric medicine: progress toward preparing the nation's physicians to care for an aging population

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article describes the progress made by medical schools in developing these programs. Academic leaders in geriatrics at all 145 accredited allopathic and osteopathic medical schools in the United States were surveyed in the winter of 2005 (68% response rate) and results compared with findings from a similar 2001 survey. Physician faculty in geriatrics at U.S. medical schools increased from 7.5 (mean) full-time equivalents (FTEs) in 2001 to 9.6 FTEs in 2005. Faculty and staff effort is mostly devoted to clinical practice (mean 36.9%) and education (mean 34.6%). A small number of programs focus on research; only six responding schools devote more than 40% of faculty effort to research. Seventy-one percent reported that their medical school required a geriatrics medical student clerkship or that their geriatric training was integrated into a required clinical rotation. In summary, from 2001 to 2005, more fellows and faculty have been recruited and trained, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, although few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. An expanded investment in training the physician workforce to care for older adults will be required to ensure adequate care for aging Americans.

Association between tetracycline or doxycycline and hepatotoxicity: a population based case-control study

BACKGROUND AND OBJECTIVE

An FDA Working Group, along with representatives of PhRMA and the American Association for the Study of Liver Diseases, as well as the Institute of Medicine Report 'To Err is Human: Building a Safer Health Care System' have suggested that post-marketing drug surveillance is a important method to decrease adverse drug events. While tetracyclines are known to cause hepatotoxicity, no post-marketing drug surveillance studies have examined the risk of developing hepatotoxicity with tetracyclines. Therefore, the objective of this study is to determine the difference in risk of hepatotoxicity in patients receiving doxycycline or tetracycline using California Medicaid claims.

METHODS

This study used a retrospective, matched case-control study using California Medicaid claims data. The cases were defined as recipients who had at least one diagnosis of hepatotoxicity any time from 1 July 1999 to 31 December 2001. One control was identified for each case, matched on age, gender and race. Logistic regression was used to determine the adjusted odds ratio (OR) and 95% confidence intervals for current users and past users of tetracycline and doxycycline. Covariates controlled for in the analysis were age, use of other hepatotoxic drugs, renal dysfunction, pregnancy, and alcohol or illicit drug use.

RESULTS

A total of 3377 cases of hepatotoxicity were identified. Current users and past users of tetracycline had a statistically significant increased risk of developing hepatotoxicity (current use OR 3.70, 95% CI 1.19-11.45; past use OR 2.72, 95% CI 1.26-5.85). Current users or past users of doxycycline did not have an increased risk of developing hepatotoxicity (current use OR 1.49, 95% CI 0.61-3.62; past use OR 1.74, 95% CI 0.99-3.06). Tetracycline was commonly used for acne, acute bronchitis and upper respiratory infections. Doxycycline was commonly used for acute bronchitis, vaginitis and acne.

DISCUSSION AND CONCLUSION

Doxycycline was potentially less hepatotoxic than tetracycline. Doxycycline could potentially be a safe substitute for tetracycline, when appropriate.

Mental health problems in children and caregivers in the emergency department setting

INTRODUCTION

Although mental health problems are increasing in the primary care sector, the prevalence of mental health problems in families presenting for nonpsychiatric complaints in the emergency department (ED) setting is generally unknown. As such, we set out to assess the frequency of mental health concerns and associated risk factors in children presenting for care in a pediatric ED.

METHODS

A total of 411 mother-child dyads were randomly selected during a 2-year period from the less acute area of a large pediatric ED. Mothers were interviewed for child mental health concerns using structured diagnostic instruments. Mothers were also interviewed for their own mental health symptoms. Risk factor analysis for the outcome of a pediatric mental health concern was performed using bivariate and multivariate techniques.

RESULTS

Of all children, 45% met criteria for a mental health concern, with 23% of all children meeting criteria for two or more mental health concerns; 21% of mothers screened positive for a mental health problem themselves. Once adjusted, children whose mothers' screened positive for a mental illness were more likely to have a mental health concern themselves.

CONCLUSION

There is a large burden of mental health concerns in children and their mothers presenting to the ED for medical care. Efficiently and accurately identifying mental illness in children presenting to a pediatric ED is the first step in the intervention process for a population that might otherwise slip through the system.

Are Internal Medicine Residency Programs Adequately Preparing Physicians to Care for the Baby Boomers? A National Survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce Study

Patients aged 65 and older account for 39% of ambulatory visits to internal medicine physicians. This article describes the progress made in training internal medicine residents to care for older Americans. Program directors in internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education were surveyed in the spring of 2005. Findings from this survey were compared with those from a similar 2002 survey to determine whether any changes had occurred. A 60% response rate was achieved (n=235). In these 3-year residency training programs, 20 programs (9%) required less than 2 weeks of clinical instruction that was specifically structured to teach geriatric care principles, 48 (21%) at least 2 weeks but less than 4 weeks, 144 (62%) at least 4 weeks but less than 6 weeks, and 21 (9%) required 6 or more weeks. As in 2002, internal medicine residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for their geriatrics training. Training was most often offered in a block format. The mean number of physician faculty per residency program dedicated to teaching geriatric medicine was 3.5 full-time equivalents (FTEs) (range 0-50), compared with a mean of 2.2 FTE faculty in 2002 (P<or=.001). Internal medicine educators are continuing to improve the training of residents so that, as they become practicing physicians, they will have the knowledge and skills in geriatric medicine to care for older adults.

A national survey of family medicine residency education in geriatric medicine: comparing findings in 2004 to 2001

BACKGROUND AND OBJECTIVES

We compared findings from this 2004 survey with our 2001 survey to determine progress in family medicine residency programs' efforts to better train residents to care for America's aging population.

METHODS

A survey was mailed and made available on-line to all 470 family medicine residency directors in the United States.

RESULTS

The response rate was 71%. Ninety-six percent of family medicine residencies have a required geriatrics curriculum, compared to 92% in 2001. There was a significant increase in the number of required lecture hours in geriatrics in 2004 as compared to 2001. Since 2001, the median number of MD geriatrics faculty per program has nearly doubled from .5 full-time equivalent (FTE) to .9 FTE. Conflicting time demands with other curricula was ranked as the most significant barrier to geriatrics education in both 2004 and 2001. However, in 2001, the attitude of residents was listed as a significant barrier by 32.1% of the program directors as compared to just 3.6% in 2004.

CONCLUSIONS

Family medicine educators are continuing to improve the training of residents to provide state-of-the-art care for the aging population. Faculty must take advantage of this period of experimentation in residency education to identify best practices for geriatrics education.

Contributions of infertility treatment to very-low-birth-weight multiple birth infants receiving neonatal intensive care

OBJECTIVE

This study was undertaken to determine proportions of very-low-birth-weight (VLBW) multiple birth infants receiving neonatal intensive care whose mothers received various types of infertility treatment and to evaluate infertility treatment-associated morbidity and mortality.

STUDY DESIGN

Study infants were multiples with birth weight 401 to 1500 g cared for in Cincinnati neonatal intensive care units from January 1996 to December 2000. Data were obtained retrospectively from the National Institute for Child Health and Human Development Neonatal Research Network registry. Use of infertility treatment (in vitro fertilization, injection or oral ovulation, and intrauterine insemination) was determined by maternal interview or chart review. The generalized estimating equation approach to logistic regression was used.

RESULTS

The study included 382 infants of 212 mothers: 201=spontaneous conception (53%), 93=in vitro fertilization (24%), 55=injection (14%), 15=oral (4%), and 18=intrauterine insemination (5%). Neither gestational age nor birth weight differed between groups. More female (58%, P=.003) and white infants (95%, P<.001) resulted from infertility treatment-induced pregnancies than from spontaneous pregnancies. Advancing gestational age significantly decreased odds for all outcomes.

CONCLUSION

Of VLBW multiples receiving neonatal intensive care, 47% are associated with infertility treatment. Infertility treatment does not influence outcomes in VLBW multiples.

Effects of antenatal glucocorticoids on outcomes of very low birth weight multifetal gestations

OBJECTIVE

The purpose of this study was to test the hypothesis that benefits of antenatal glucocorticoids to reduce death or major morbidities are similar in very low birth weight multiple and singleton infants.

STUDY DESIGN

Infants with birth weight of 401 to 1500 g who were born from May 1991 through December 1999 were evaluated with the use of the National Institute for Child Health and Human Development Neonatal Research Network registry data. The generalized estimating equations approach to multivariable logistic regression was used, with interaction between multifetal gestation and antenatal glucocorticoids as the primary independent variable.

RESULTS

Mothers of multiple infants were more likely to receive antenatal glucocorticoids than mothers of singleton infants (66% vs 56%; P <.01). No interaction between multifetal gestation and antenatal glucocorticoids was noted for any study outcomes. The odds of death or major morbidity was decreased by antenatal glucocorticoids, advancing gestational age, increasing birth weight, female gender, and nonwhite race.

CONCLUSION

If exposed to antenatal glucocorticoids, very low birth weight infants of multifetal gestations and very low birth weight singleton infants have similar risks of death or major morbidity.

Diagnostic testing

The results of cardiac tests must always be interpreted through the lens of pretest probabilities created by the history and the physical examination. Tests should be chosen with a clear diagnostic and prognostic purpose in mind. A clear understanding of the relationship between the history and physical examination and more technologic diagnostic testing improves the primary care physician's ability to evaluate potential cardiac disease in an efficient and cost-effective manner.

4,4'-methylene-bis-ortho-chloro-aniline (MBOCA): absorption and excretion after skin application and gavage

4,4'-methylene-bis-ortho-chloro-aniline ( MBOCA ) is an aromatic amine and industrial chemical that has been shown to cause cancer of several different organs in rats and mice and bladder cancer in dogs. The purpose of this study was to determine the efficacy of using urinary concentrations of MBOCA as a means for evaluating extent of exposure. Male Sprague-Dawley rats were given MBOCA and [14C] MBOCA by either gavage or skin application. Concentrations and amounts of 14C were measured in urine, feces, skin and total carcasses, and parent MBOCA in urine at several intervals after application. The percentages of administered doses excreted and retained in the animals were calculated and comparisons made. Within 72 hr after gavage 16.5% of the administered compound was excreted in urine as 14C but only 0.25% as parent MBOCA . In the same interval after skin application a maximum of 2.54% of administered MBOCA was excreted as 14C but only 0.008% as parent MBOCA . Seventy-two hours after gavage 13.7% of the administered dose was retained in the tissues, and after skin absorption 5-13% was retained. With gavage the rate of excretion of 14C in urine and feces was very high in the first 24 hr (68.3%) but fell off rapidly (2.07%) by the third day. After skin absorption the rates of excretion of 14C were fairly constant over a 3-day period. Less MBOCA was absorbed from the skin if the skin was washed within 8 hr after application, as compared to waiting 24 hr or not washing at all. The amount of parent MBOCA detected in urine is a very small amount of that applied or absorbed. The percentage detected and the rates of excretion depend upon the route of administration, and the interval between exposure and sampling. For these reasons urinary analysis for MBOCA can be used only as very imprecise indicators of extent of recent exposure.