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Ganz DA, Esserman D, Latham NK, Kane M, Min LC, Gill TM, Reuben DB, Peduzzi P, Greene EJ. Validation of a Rule-Based ICD-10-CM Algorithm to Detect Fall Injuries in Medicare Data. J Gerontol A Biol Sci Med Sci 2024:glae096. [PMID: 38566617 DOI: 10.1093/gerona/glae096] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Diagnosis-code-based algorithms to identify fall injuries in Medicare data are useful for ascertaining outcomes in interventional and observational studies. However, these algorithms have not been validated against a fully external reference standard, in ICD-10-CM, or in Medicare Advantage (MA) data. METHODS We linked self-reported fall injuries leading to medical attention (FIMA) from the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial (reference standard) to Medicare fee-for-service (FFS) and MA data from 2015-2019. We measured the area under the receiver operating characteristic curve (AUC) based on sensitivity and specificity of a diagnosis-code-based algorithm against the reference standard for presence or absence of ≥1 FIMA within a specified window of dates, varying the window size to obtain points on the curve. We stratified results by source (FFS versus MA), trial arm (intervention versus control), and STRIDE's ten participating healthcare systems. RESULTS Both reference standard data and Medicare data were available for 4941 (of 5451) participants. The reference standard and algorithm identified 2054 and 2067 FIMA, respectively. The algorithm had 45% sensitivity (95% confidence interval [CI], 43%-47%) and 99% specificity (95% CI, 99%-99%) to identify reference standard FIMA within the same calendar month. The AUC was 0.79 (95% CI, 0.78-0.81) and was similar by FFS or MA data source or trial arm, but showed variation among STRIDE healthcare systems (AUC range by healthcare system, 0.71 to 0.84). CONCLUSIONS An ICD-10-CM algorithm to identify fall injuries demonstrated acceptable performance against an external reference standard, in both MA and FFS data.
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Affiliation(s)
- David A Ganz
- Department of Medicine, David Geffen School of Medicine at UCLA; Los Angeles, CA
- Geriatric Research, Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System; Los Angeles, CA
| | - Denise Esserman
- Department of Biostatistics; Yale School of Public Health; New Haven, CT
| | - Nancy K Latham
- Boston Claude D. Pepper Older Americans Independence Center; Research Program in Men's Health: Aging and Metabolism; Brigham and Women's Hospital, Harvard Medical School; Boston, MA
| | - Michael Kane
- Department of Biostatistics; Yale School of Public Health; New Haven, CT
| | - Lillian C Min
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan; Ann Arbor, MI and Ann Arbor VA Medical Center, Center for Clinical Management Research and Geriatric Research Education Clinical Center (GRECC); Ann Arbor, MI
| | - Thomas M Gill
- Department of Internal Medicine, Yale School of Medicine; New Haven, CT
| | - David B Reuben
- Department of Medicine, David Geffen School of Medicine at UCLA; Los Angeles, CA
| | - Peter Peduzzi
- Department of Biostatistics; Yale School of Public Health; New Haven, CT
| | - Erich J Greene
- Department of Biostatistics; Yale School of Public Health; New Haven, CT
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Hoffman GJ, Alexander NB, Ha J, Nguyen T, Min LC. Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit? Health Serv Res 2024; 59:e14246. [PMID: 37806664 PMCID: PMC10771912 DOI: 10.1111/1475-6773.14246] [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] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVE To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs). DATA SOURCES AND STUDY SETTING Secondary data from Medicare were used. STUDY DESIGN Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities). DATA COLLECTION Not applicable. PRINCIPAL FINDINGS We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001). CONCLUSIONS HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.
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Affiliation(s)
- Geoffrey J. Hoffman
- Department of Systems, Populations and LeadershipUniversity of Michigan School of NursingAnn ArborMichiganUSA
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMichiganUSA
| | - Neil B. Alexander
- Department of Medicine, Division of Geriatric and Palliative MedicineUniversity of MichiganAnn ArborMichiganUSA
- Geriatric Research Education and Clinical Care Center (GRECC)VA Medical CenterAnn ArborMichiganUSA
| | - Jinkyung Ha
- Division of Geriatric and Palliative Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Thuy Nguyen
- Department of Health Policy and ManagementUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Lillian C. Min
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMichiganUSA
- Department of Medicine, Division of Geriatric and Palliative MedicineUniversity of MichiganAnn ArborMichiganUSA
- Veterans Affairs Center for Clinical Management and Research (CCMR)VA Medical CenterAnn ArborMichiganUSA
- VA Center for Clinical Management ResearchAnn Arbor VA Healthcare SystemAnn ArborMichiganUSA
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Pichan CM, Anderson CE, Min LC, Blazek MC. Geriatric Education on Telehealth (GET) Access: A medical student volunteer program to increase access to geriatric telehealth services at the onset of COVID-19. J Telemed Telecare 2023; 29:816-824. [PMID: 34152885 DOI: 10.1177/1357633x211023924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The coronavirus disease 2019 pandemic placed an unprecedented demand on health systems to rapidly shift ambulatory in-person care to virtual care. Geriatric patients face more challenges with video visit access compared to younger patients due to discomfort with technology and less access to devices and internet. Medical students at the University of Michigan created an initiative to improve access to and comfort with video visits for geriatric patients. The program's goals were to (a) explore options for the delivery of personalized training to older adults, (b) create materials for volunteers to successfully navigate conversations with patients and caregivers, (c) provide patients one-to-one remote guidance while identifying and overcoming barriers-with practice sessions to increase comfort, (d) share with the larger health system, and (e) ensure program sustainability. Over a 10-week evaluation period, providers whose patients worked with our geriatric education on telehealth access volunteers had a video visit rate of 43% compared to 19.2% prior to participation in the program (adjusted odds ratio = 3.38, 95% confidence interval = 2.49, 4.59), ultimately providing a platform for geriatric patients to foster stronger connections with their providers, while increasing Michigan Medicine's overall proportion of video telehealth visits.
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Affiliation(s)
- Cayla M Pichan
- Department of Internal Medicine, University of Michigan Medical School, USA
| | - Clare E Anderson
- Department of Internal Medicine, University of Michigan Medical School, USA
| | - Lillian C Min
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, USA
| | - Mary C Blazek
- Department of Psychiatry, University of Michigan Medical School, USA
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4
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Norcott AE, Min LC, Bynum JPW. Preoperative Cognitive Evaluations: An Opportunity to Protect the Vulnerable Brain. Ann Surg 2021; 274:e85-e87. [PMID: 33156058 PMCID: PMC10653644 DOI: 10.1097/sla.0000000000004573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Alexandra E Norcott
- Department of Internal Medicine, Division of Geriatric Research, Education, and Clinical Centers (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, Division of Geriatric & Palliative Medicine, Michigan Medicine: University of Michigan, Ann Arbor, Michigan
| | - Lillian C Min
- Department of Internal Medicine, Division of Geriatric Research, Education, and Clinical Centers (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, Division of Geriatric & Palliative Medicine, Michigan Medicine: University of Michigan, Ann Arbor, Michigan
| | - Julie P W Bynum
- Department of Internal Medicine, Division of Geriatric & Palliative Medicine, Michigan Medicine: University of Michigan, Ann Arbor, Michigan
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Miller AL, Holcomb AJ, Parikh AS, Richards JM, Rathi VK, Goldfarb JW, Remenschneider AK, Bergmark RW, Annino DJ, Goguen LA, Rettig EM, Deschler DG, Emerick KS, Lin DT, Richmon JD, Chan CL, Min LC, Uppaluri R, Varvares MA. Assessment of Preoperative Functional Status Prior to Major Head and Neck Surgery: A Pilot Study. Otolaryngol Head Neck Surg 2021; 166:688-695. [PMID: 34154446 DOI: 10.1177/01945998211019306] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To demonstrate feasibility of a recently developed preoperative assessment tool, the Vulnerable Elders Surgical Pathways and Outcomes Analysis (VESPA), to characterize the baseline functional status of patients undergoing major head and neck surgery and to examine the relationship between preoperative functional status and postoperative outcomes. STUDY DESIGN Case series with planned data collection. SETTING Two tertiary care academic hospitals. METHODS The VESPA was administered prospectively in the preoperative setting. Data on patient demographics, ablative and reconstructive procedures, and outcomes including total length of stay, discharge disposition, delay in discharge, or complex discharge planning (delay or change in disposition) were collected via retrospective chart review. VESPA scores were calculated and risk categories were used to estimate risk of adverse postoperative outcomes using multivariate logistic regression for categorical outcomes and linear regression for continuous variables. RESULTS Fifty-eight patients met study inclusion criteria. The mean (SD) age was 66.4 (11.9) years, and 58.4% of patients were male. Nearly one-fourth described preoperative difficulty in either a basic or instrumental activity of daily living, and 17% were classified as low functional status (ie, high risk) according to the VESPA. Low functional status did not independently predict length of stay but was associated with delayed discharge (odds ratio [OR], 5.0; 95% CI, 1.2-21.3; P = .030) and complex discharge planning (OR, 5.7; 95% CI, 1.34-24.2; P = .018). CONCLUSION The VESPA can identify major head and neck surgical patients with low preoperative functional status who may be at risk for delayed or complex discharge planning. These patients may benefit from enhanced preoperative counseling and more comprehensive discharge preparation.
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Affiliation(s)
- Ashley L Miller
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew J Holcomb
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Anuraag S Parikh
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julianne M Richards
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Vinay K Rathi
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Business School, Boston, Massachusetts, USA
| | - Jeremy W Goldfarb
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aaron K Remenschneider
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - Regan W Bergmark
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Patient Reported Outcomes, Value and Experience (PROVE) Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Donald J Annino
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Laura A Goguen
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Eleni M Rettig
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin S Emerick
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Chiao-Li Chan
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Lillian C Min
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Geriatric Research Education Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Ravindra Uppaluri
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mark A Varvares
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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6
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Gill TM, Bhasin S, Reuben DB, Latham NK, Araujo K, Ganz DA, Boult C, Wu AW, Magaziner J, Alexander N, Wallace RB, Miller ME, Travison TG, Greenspan SL, Gurwitz JH, Rich J, Volpi E, Waring SC, Manini TM, Min LC, Teresi J, Dykes PC, McMahon S, McGloin JM, Skokos EA, Charpentier P, Basaria S, Duncan PW, Storer TW, Gazarian P, Allore HG, Dziura J, Esserman D, Carnie MB, Hanson C, Ko F, Resnick NM, Wiggins J, Lu C, Meng C, Goehring L, Fagan M, Correa-de-Araujo R, Casteel C, Peduzzi P, Greene EJ. Effect of a Multifactorial Fall Injury Prevention Intervention on Patient Well-Being: The STRIDE Study. J Am Geriatr Soc 2020; 69:173-179. [PMID: 33037632 PMCID: PMC8178516 DOI: 10.1111/jgs.16854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 07/24/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/OBJECTIVES In the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study, a multifactorial intervention was associated with a nonsignificant 8% reduction in time to first serious fall injury but a significant 10% reduction in time to first self-reported fall injury relative to enhanced usual care. The effect of the intervention on other outcomes important to patients has not yet been reported. We aimed to evaluate the effect of the intervention on patient well-being including concern about falling, anxiety, depression, physical function, and disability. DESIGN Pragmatic cluster-randomized trial of 5,451 community-living persons at high risk for serious fall injuries. SETTING A total of 86 primary care practices within 10 U.S. healthcare systems. PARTICIPANTS A random subsample of 743 persons aged 75 and older. MEASUREMENTS The well-being measures, assessed at baseline, 12 months, and 24 months, included a modified version of the Fall Efficacy Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression scales, and Late-Life Function and Disability Instrument. RESULTS Participants in the intervention (n = 384) and control groups (n = 359) were comparable in age: mean (standard deviation) of 81.9 (4.7) versus 81.8 (5.0) years. Mean scores were similar between groups at 12 and 24 months for concern about falling, physical function, and disability, whereas the intervention group's mean scores on anxiety and depression were .7 points lower (i.e., better) at 12 months and .6 to .8 points lower at 24 months. For each of these outcomes, differences between the groups' adjusted least square mean changes from baseline to 12 and 24 months, respectively, were quantitatively small. The overall difference in means between groups over 2 years was statistically significant only for depression, favoring the intervention: -1.19 (99% confidence interval, -2.36 to -.02), with 3.5 points representing a minimally important difference. CONCLUSIONS STRIDE's multifactorial intervention to reduce fall injuries was not associated with clinically meaningful improvements in patient well-being.
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Affiliation(s)
- Thomas M Gill
- Yale Claude D. Pepper Older Americans Independence Center, Yale University, New Haven, Connecticut, USA
| | - Shalender Bhasin
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nancy K Latham
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katy Araujo
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - David A Ganz
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Geriatric Research, Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Chad Boult
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Albert W Wu
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Jay Magaziner
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | - Michael E Miller
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Thomas G Travison
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan L Greenspan
- Pittsburgh Claude D. Pepper Older Americans Independence Center, Division of Geriatrics and Gerontology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of Reliant Medical Group, Fallon Health and University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jeremy Rich
- HealthCare Partners, El Segundo, California, USA
| | - Elena Volpi
- University of Texas Medical Branch Claude D. Pepper Older Americans Independence Center; Sealy Center on Aging, The University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Todd M Manini
- Department of Aging and Geriatric Research, University of Florida, Gainesville, Florida, USA
| | | | - Jeanne Teresi
- Research Division, Hebrew Home at Riverdale, RiverSpring Health, Bronx, New York, USA
| | | | - Siobhan McMahon
- School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joanne M McGloin
- Yale Claude D. Pepper Older Americans Independence Center, Yale University, New Haven, Connecticut, USA
| | - Eleni A Skokos
- Yale Claude D. Pepper Older Americans Independence Center, Yale University, New Haven, Connecticut, USA
| | - Peter Charpentier
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - Shehzad Basaria
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pamela W Duncan
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Thomas W Storer
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Priscilla Gazarian
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of Massachusetts, Boston, Massachusetts, USA
| | - Heather G Allore
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - James Dziura
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - Denise Esserman
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | | | | | - Fred Ko
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Neil M Resnick
- Pittsburgh Claude D. Pepper Older Americans Independence Center, Division of Geriatrics and Gerontology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Charles Lu
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - Can Meng
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - Lori Goehring
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Maureen Fagan
- University of Miami Health System, Miami, Florida, USA
| | | | | | - Peter Peduzzi
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - Erich J Greene
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
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7
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Abstract
IMPORTANCE To date, measurement and treatment of older adult fall injury has been siloed within specific care settings, such as a hospital or within a nursing home or community. Little is known about changes in fall risk across care settings. Understanding the occurrence of falls across settings has implications for measuring and incentivizing high-value care across care settings. OBJECTIVE To estimate the risk of older adult fall injury within and across discrete periods during a 12-month care episode anchored by an acute hospitalization. DESIGN, SETTING, AND PARTICIPANTS This cohort study is a longitudinal analysis of 12-month periods that include an anchor hospital stay using national data from 2006 to 2014. Participants included older (aged ≥65 years) Medicare fee-for-service beneficiaries from the Health and Retirement Study. Weekly fall injury rates were computed for 4 periods compared with the anchor hospitalization: at baseline (1-6 months before hospitalization), just before (<1 month before hospitalization), just after (<1 month after hospitalization), and at follow-up (1-6 months after hospitalization). Piecewise logistic regression models estimated weekly marginal risk of fall injury within each period, adjusting for sociodemographic and health characteristics. Fall injury risks for high-risk beneficiaries with a fall injury during the anchor hospitalization were also estimated. Data analysis was performed from November 2019 to April 2020. MAIN OUTCOMES AND MEASURES Fall injuries. RESULTS In total, 10 106 anchor hospitalizations for 4101 beneficiaries (mean [SD] age, 77.1 [7.6] years; 5912 hospitalizations among women [58.5%]) were identified. The overall fall injury risk was 0.77%. In adjusted models, marginal increases in weekly fall injury risk just before hospitalization (0.27 percentage points [95% CI, 0.22 to 0.33 percentage points], or 30.0%; P < .001) were 4 times greater than decreases just after hospitalization (-0.18 percentage points [95% CI, -0.23 to -0.13 percentage points], or -9.2%; P < .001)]. A greater risk differential before and after hospitalization was observed for patients with an inpatient fall injury (1.89 percentage points [95% CI, 1.37 to 2.40], or 309.8%; P < .001; vs -0.39 percentage points [95% CI, -0.73 to -0.04], or -11.6%; P = .03). CONCLUSIONS AND RELEVANCE An episode-based assessment of fall injury illustrates substantial variability in period-specific risks over an extended period including an anchor hospitalization. Risk transitions between periods include sizable increases just before hospitalization that do not fully subside after hospital discharge. Financial incentives to coordinate hospital and posthospital care for patients at risk for fall injury are needed. These could include bundled payments for fall injury episodes that incentivize coordination across settings.
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Affiliation(s)
- Geoffrey J. Hoffman
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Mary E. Tinetti
- Department of Medicine (Geriatrics), Yale University, New Haven, Connecticut
- School of Public Health, Yale University, New Haven, Connecticut
| | - Jinkyung Ha
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Neil B. Alexander
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Geriatric Research Education Clinical Center, VA Medical Center, Ann Arbor, Michigan
| | - Lillian C. Min
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Geriatric Research Education Clinical Center, VA Medical Center, Ann Arbor, Michigan
- Veterans Affairs Center for Clinical Management and Research, VA Medical Center, Ann Arbor, Michigan
- Institute for Social Research, University of Michigan, Ann Arbor
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8
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Hoffman GJ, Min LC, Liu H, Marciniak DJ, Mody L. Role of Post‐Acute Care in Readmissions for Preexisting Healthcare‐Associated Infections. J Am Geriatr Soc 2019; 68:370-378. [DOI: 10.1111/jgs.16208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/27/2019] [Accepted: 09/02/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Geoffrey J. Hoffman
- Department of Systems, Populations and LeadershipUniversity of Michigan School of Nursing Ann Arbor Michigan
- Institute for Healthcare Policy and InnovationUniversity of Michigan Ann Arbor Michigan
| | - Lillian C. Min
- Institute for Healthcare Policy and InnovationUniversity of Michigan Ann Arbor Michigan
- Department of Medicine, Division of Geriatric and Palliative MedicineUniversity of Michigan Ann Arbor Michigan
- Veterans Affairs Center for Clinical Management and Research (CCMR)VA Medical Center Ann Arbor Michigan
- Institute for Social ResearchUniversity of Michigan Ann Arbor Michigan
- Geriatrics Research Education and Clinical CenterVA Ann Arbor Healthcare System Ann Arbor Michigan
| | - Haiyin Liu
- Department of Systems, Populations and LeadershipUniversity of Michigan School of Nursing Ann Arbor Michigan
| | | | - Lona Mody
- Department of Medicine, Division of Geriatric and Palliative MedicineUniversity of Michigan Ann Arbor Michigan
- Geriatrics Research Education and Clinical CenterVA Ann Arbor Healthcare System Ann Arbor Michigan
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9
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Abstract
IMPORTANCE Falls are common among older adults, particularly those with previous falls and cognitive impairment and in the postdischarge period. Hospitals have financial incentives to reduce both inpatient falls and hospital readmissions, yet little is known about whether fall-related injuries (FRIs) are common diagnoses for 30-day hospital readmissions. OBJECTIVE To compare fall-related readmissions with other leading rehospitalization diagnoses, including for patients at greatest risk of readmission. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of the Hospital Cost and Utilization Project's Nationwide Readmissions Database of nationally representative US hospital discharges among Medicare beneficiaries aged 65 years and older from January 1, 2013, to November 30, 2014. The prevalence and ranking of FRIs compared with other diagnostic factors for 30-day unplanned hospital-wide readmissions were determined, overall and for 2 acute geriatric cohorts, classified by fall injury or cognitive impairment diagnoses observed at the index admission. Analyses were also stratified by patient discharge disposition (home, home health care, skilled nursing facility). Analyses were conducted from February 1, 2018, to February 26, 2018. MAIN OUTCOMES AND MEASURES Unplanned hospital-wide readmission within 30 days of discharge. RESULTS From the database, 8 382 074 eligible index admissions were identified, including 746 397 (8.9%) in the FRI cohort and 1 367 759 (16.3%) in the cognitive impairment cohort. Among the entire 8 382 074-discharge cohort, mean (SD) age was 77.7 (7.8) years and 4 736 281 (56.5%) were female. Overall, 1 205 962 (14.4%) of index admissions resulted in readmission, with readmission rates of 12.9% for those with a previous fall and 16.0% for patients with cognitive impairment. Overall, FRIs ranked as the third-leading readmission diagnosis, accounting for 60 954 (5.1%) of all readmission diagnoses. Within the novel acute geriatric cohorts, FRIs were the second-leading diagnosis for readmission both for patients with an FRI at index admission (10.3% of all readmission diagnoses) and those with cognitive impairment (7.0% of all readmission diagnoses). For those with an FRI at index admission and discharged home or to home health care, FRIs were the leading readmission diagnosis. CONCLUSIONS AND RELEVANCE This study found that posthospital FRIs were a leading readmission diagnosis, particularly for patients originally admitted with a FRI or cognitive impairment. Targeting at-risk hospitalized older adults, particularly those discharged to home or home health care, is an underexplored, cost-effective mechanism with potential to reduce readmissions and improve patient care.
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Affiliation(s)
- Geoffrey J. Hoffman
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Haiyin Liu
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor
| | - Neil B. Alexander
- Geriatric Research Education and Clinical Care Center (GRECC), VA Medical Center, Ann Arbor, Michigan
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Mary Tinetti
- Division of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- School of Public Health, Yale University, New Haven, Connecticut
| | - Thomas M. Braun
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Lillian C. Min
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor
- Veterans Affairs Center for Clinical Management and Research (CCMR), VA Medical Center, Ann Arbor, Michigan
- Institute for Social Research, University of Michigan, Ann Arbor
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Chan CL, Diehl KM, Hall KE, Palazzolo WC, Pollock Y, Min LC. Unrealistic Postsurgical Expectation of Independence Predicts Complex Hospital Discharge. J Surg Res 2019; 235:501-512. [PMID: 30691835 PMCID: PMC6355161 DOI: 10.1016/j.jss.2018.10.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 04/19/2018] [Revised: 10/03/2018] [Accepted: 10/18/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND Careful discharge planning for older surgical patients can reduce length of stay, readmission, and cost. We hypothesized that patients who overestimate their self-care ability before surgery are more likely to have complex postoperative discharge planning. MATERIALS AND METHODS The Vulnerable Elders Surgical Pathways and Outcomes Assessment is a brief preoperative assessment that can identify older (age ≥70) patients with multidimensional geriatric risk, defined by all three of the following: (1) physical or cognitive impairment, (2) living alone, and (3) lack of handicap-accessible home. The Vulnerable Elders Surgical Pathways and Outcomes Assessment also asks a novel postoperative self-care ability question, whether patient can independently provide self-care for several hours after discharge. Classifying patients into four groups based on multidimensional geriatric risk (full versus none or partial) and the self-care ability question (yes or no), we hypothesized those with unrealistic postsurgical expectation of independence (UPSI) (both fully at risk and "yes" to self-care ability question) would be at the increased risk for complex discharge planning. Complex discharge planning was defined as prolonged stay because of nonmedical reasons or multiple changes in discharge plans. RESULTS In 382 hospitalizations of ≥2 d, 366 had a nonmissing answer to the self-care question; of those 5% had UPSI and 6.3% needed complex discharge planning. The UPSI group was independently associated with greater risk of complex discharge planning compared with the normal group (odds ratio = 4.3 [95% confidence interval, 1.1-16.1]). CONCLUSIONS Complex discharges were rare, but predictable by preoperative geriatric screening. Patients with UPSI should be targeted for postoperative care planning in advance of surgery.
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Affiliation(s)
- Chiao-Li Chan
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kathleen M Diehl
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Karen E Hall
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; VA Ann Arbor Healthcare System Geriatric Research Education and Clinical Centers, Ann Arbor, Michigan
| | | | - YaoYao Pollock
- San Francisco Division of Hematology and Oncology, University of California San Francisco, San Francisco, California
| | - Lillian C Min
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; VA Ann Arbor Healthcare System Geriatric Research Education and Clinical Centers, Ann Arbor, Michigan.
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Hoffman GJ, Ha J, Alexander NB, Langa KM, Tinetti M, Min LC. Underreporting of Fall Injuries of Older Adults: Implications for Wellness Visit Fall Risk Screening. J Am Geriatr Soc 2018; 66:1195-1200. [PMID: 29665016 PMCID: PMC6105546 DOI: 10.1111/jgs.15360] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare the accuracy of and factors affecting the accuracy of self-reported fall-related injuries (SFRIs) with those of administratively obtained FRIs (AFRIs). DESIGN Retrospective observational study SETTING: United States PARTICIPANTS: Fee-for-service Medicare beneficiaries aged 65 and older (N=47,215). MEASUREMENTS We used 24-month self-report recall data from 2000-2012 Health and Retirement Study data to identify SFRIs and linked inpatient, outpatient, and ambulatory Medicare data to identify AFRIs. Sensitivity and specificity were assessed, with AFRIs defined using the University of California at Los Angeles/RAND algorithm as the criterion standard. Logistic regression models were used to identify sociodemographic and health predictors of sensitivity. RESULTS Overall sensitivity and specificity were 28% and 92%. Sensitivity was greater for the oldest adults (38%), women (34%), those with more functional limitations (47%), and those with a prior fall (38%). In adjusted results, several participant factors (being female, being white, poor functional status, depression, prior falls) were modestly associated with better sensitivity and specificity. Injury severity (requiring hospital care) most substantively improved SFRI sensitivity (73%). CONCLUSION An overwhelming 72% of individuals who received Medicare-reimbursed health care for FRIs failed to report a fall injury when asked. Future efforts to address underreporting in primary care of nonwhite and healthier older adults are critical to improve preventive efforts. Redesigned questions-for example, that address stigma of attributing injury to falling-may improve sensitivity.
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Affiliation(s)
- Geoffrey J. Hoffman
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI
| | - Jinkyung Ha
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI
| | - Neil B. Alexander
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI
- Geriatric Research Education and Clinical Care Center (GRECC), VA Medical Center, Ann Arbor, MI
| | - Kenneth M. Langa
- Veterans Affairs Center for Clinical Management and Research (CCMR), VA Medical Center, Ann Arbor, MI
- Institute for Social Research, University of Michigan, Ann Arbor, MI
- Department of Medicine, Division of General Internal Medicine, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Mary Tinetti
- Department of Medicine (Geriatrics), Yale University, New Haven, CT
- School of Public Health, Yale University, New Haven, CT
| | - Lillian C. Min
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI
- Geriatric Research Education and Clinical Care Center (GRECC), VA Medical Center, Ann Arbor, MI
- Veterans Affairs Center for Clinical Management and Research (CCMR), VA Medical Center, Ann Arbor, MI
- Institute for Social Research, University of Michigan, Ann Arbor, MI
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12
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Miller AL, Englesbe MJ, Diehl KM, Chan CL, Cron DC, Derstine BA, Palazzolo WC, Hall KE, Wang SC, Min LC. Preoperative Psoas Muscle Size Predicts Postoperative Delirium in Older Adults Undergoing Surgery: A Pilot Cohort Study. J Am Geriatr Soc 2016; 65:e23-e24. [PMID: 27991649 DOI: 10.1111/jgs.14571] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ashley L Miller
- School of Medicine, University of Michigan, Ann Arbor, Michigan.,Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Michael J Englesbe
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan.,Morphomics Analysis Group, University of Michigan Health System, Ann Arbor, Michigan
| | - Kathleen M Diehl
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Chiao-Li Chan
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - David C Cron
- School of Medicine, University of Michigan, Ann Arbor, Michigan.,Morphomics Analysis Group, University of Michigan Health System, Ann Arbor, Michigan
| | - Brian A Derstine
- Morphomics Analysis Group, University of Michigan Health System, Ann Arbor, Michigan
| | - William C Palazzolo
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Karen E Hall
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan.,Geriatric, Research, Education, and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Stewart C Wang
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan.,Morphomics Analysis Group, University of Michigan Health System, Ann Arbor, Michigan
| | - Lillian C Min
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan.,Geriatric, Research, Education, and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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Abstract
OBJECTIVES To determine whether receiving more recommended diabetes mellitus (DM) care processes (tests and screenings) would translate into better 9-year survival for middle-aged and older adults. DESIGN Longitudinal mortality analysis using the Health and Retirement Study Diabetes Mailout Survey. SETTING Health and Retirement Study (HRS). PARTICIPANTS Individuals aged 51 and older (n = 1,879; mean age 68.8 ± 8.7, 26.5% aged ≥75) with self-reported DM who completed the Diabetes Mailout Survey and the core 2002 HRS survey. MEASUREMENTS A composite measure of five self-reported diabetes mellitus care process measures were dichotomized as greater (3-5 processes) versus fewer (0-2 processes) care processes provided. Cox proportional hazards models were used to test relationships between reported measures and mortality, controlling for sociodemographic characteristics, function, comorbidities, geriatric conditions, and insulin use. RESULTS Prevalence of self-reported care processes was 80.1% for glycosylated hemoglobin test, 75.9% for urine test, 67.5% for eye examination, 67.7% for aspirin counseling, and 48.2% for diabetes education. In 9 years, 32.1% respondents died. Greater care correlated with 24% lower risk of dying (adjusted hazard ratio = 0.76, 95% confidence interval = 0.64-0.91) at 9-year follow up. When respondents were age-stratified (≥75 vs <75) longer survival was statistically significant only in the older age group. CONCLUSION Although it is not possible to account for differences in adherence to care that may also affect survival, this study demonstrates that monitoring of and counseling about types of DM care processes are associated with long-term survival benefit even in individuals aged 75 and older with DM.
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Affiliation(s)
- Benjamin H Han
- Division of Geriatric Medicine and Palliative Care, Department of Medicine, School of Medicine, New York University, New York, New York
| | - Caroline S Blaum
- Division of Geriatric Medicine and Palliative Care, Department of Medicine, School of Medicine, New York University, New York, New York
| | - Rosie E Ferris
- Division of Geriatric Medicine and Palliative Care, Department of Medicine, School of Medicine, New York University, New York, New York
| | - Lillian C Min
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan.,Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Pearl G Lee
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan.,Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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14
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Sussman JB, Kerr EA, Saini SD, Holleman RG, Klamerus ML, Min LC, Vijan S, Hofer TP. Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients With Diabetes Mellitus. JAMA Intern Med 2015; 175:1942-9. [PMID: 26502220 PMCID: PMC9617259 DOI: 10.1001/jamainternmed.2015.5110] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Older patients with diabetes mellitus receiving medical treatment whose blood pressure (BP) or blood glucose level are potentially dangerously low are rarely deintensified. Given the established risks of low blood pressure and blood glucose, this is a major opportunity to decrease medication harm. OBJECTIVE To examine the rate of BP- and blood glucose-lowering medicine deintensification among older patients with type 1 or 2 diabetes mellitus who potentially receive overtreatment. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study conducted using data from the US Veterans Health Administration. Participants included 211 667 patients older than 70 years with diabetes mellitus who were receiving active treatment (defined as BP-lowering medications other than angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or glucose-lowering medications other than metformin hydrochloride) from January 1 to December 31, 2012. Data analysis was performed December 10, 2013, to July 20, 2015. EXPOSURES Participants were eligible for deintensification of treatment if they had low BP or a low hemoglobin A1c (HbA1c) level in their last measurement in 2012. We defined very low BP as less than 120/65 mm Hg, moderately low as systolic BP of 120 to 129 mm Hg or diastolic BP (DBP) less than 65 mm Hg, very low HbA1c as less than 6.0%, and moderately low HbA1c as 6.0% to 6.4%. All other values were not considered low. MAIN OUTCOMES AND MEASURES Medication deintensification, defined as discontinuation or dosage decrease within 6 months after the index measurement. RESULTS The actively treated BP cohort included 211,667 participants, more than half of whom had moderately or very low BP levels. Of 104,486 patients with BP levels that were not low, treatment in 15.1% was deintensified. Of 25,955 patients with moderately low BP levels, treatment in 16.0% was deintensified. Among 81,226 patients with very low BP levels, 18.8% underwent BP medication deintensification. Of patients with very low BP levels whose treatment was not deintensified, only 0.2% had a follow-up BP measurement that was elevated (BP ≥140/90 mm Hg). The actively treated HbA1c cohort included 179,991 participants. Of 143,305 patients with HbA1c levels that were not low, treatment in 17.5% was deintensified. Of 23,769 patients with moderately low HbA1c levels, treatment in 20.9% was deintensified. Among 12,917 patients with very low HbA1c levels, 27.0% underwent medication deintensification. Of patients with very low HbA1c levels whose treatment was not deintensified, fewer than 0.8% had a follow-up HbA1c measurement that was elevated (≥7.5%). CONCLUSIONS AND RELEVANCE Among older patients whose treatment resulted in very low levels of HbA1c or BP, 27% or fewer underwent deintensification, representing a lost opportunity to reduce overtreatment. Low HbA1c or BP values or low life expectancy had little association with deintensification events. Practice guidelines and performance measures should place more focus on reducing overtreatment through deintensification.
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Affiliation(s)
- Jeremy B Sussman
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Eve A Kerr
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Sameer D Saini
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Rob G Holleman
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Mandi L Klamerus
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Lillian C Min
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Sandeep Vijan
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Timothy P Hofer
- Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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15
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Mody L, Krein SL, Saint S, Min LC, Montoya A, Lansing B, McNamara SE, Symons K, Fisch J, Koo E, Rye RA, Galecki A, Kabeto MU, Fitzgerald JT, Olmsted RN, Kauffman CA, Bradley SF. A targeted infection prevention intervention in nursing home residents with indwelling devices: a randomized clinical trial. JAMA Intern Med 2015; 175:714-23. [PMID: 25775048 PMCID: PMC4420659 DOI: 10.1001/jamainternmed.2015.132] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Indwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs). Inadequate care of residents with these devices contributes to high rates of multidrug-resistant organisms (MDROs) and device-related infections in NHs. OBJECTIVE To test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both. INTERVENTIONS Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education. MAIN OUTCOMES AND MEASURES The primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident's participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables. RESULTS In total, 418 NH residents with indwelling devices were enrolled, with 34,174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections. CONCLUSIONS AND RELEVANCE Our multimodal TIP intervention reduced the overall MDRO prevalence density, new methicillin-resistant S aureus acquisitions, and clinically defined catheter-associated urinary tract infection rates in high-risk NH residents with indwelling devices. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01062841.
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Affiliation(s)
- Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor2Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sarah L Krein
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan4Division of General Medicine, University of Michigan Health System, Ann Arbor
| | - Sanjay Saint
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan4Division of General Medicine, University of Michigan Health System, Ann Arbor
| | - Lillian C Min
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor2Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Ana Montoya
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Bonnie Lansing
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Sara E McNamara
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Kathleen Symons
- Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jay Fisch
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor6currently with the Rosenstiel School of Marine and Atmospheric Science, University of Miami, Miami, Florida
| | - Evonne Koo
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Ruth Anne Rye
- currently a long-term care infection prevention and control consultant in Hemlock, Michigan
| | - Andrzej Galecki
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor8Department of Biostatistics, University of Michigan Medical School, Ann Arbor
| | - Mohammed U Kabeto
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - James T Fitzgerald
- Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan9Department of Medical Education, University of Michigan Medical School, Ann Arbor
| | - Russell N Olmsted
- Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan
| | - Carol A Kauffman
- Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan11Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Suzanne F Bradley
- Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan11Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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Affiliation(s)
- Christine T Cigolle
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor2Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Jinkyung Ha
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Lillian C Min
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Pearl G Lee
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Tanya R Gure
- Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - Neil B Alexander
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Caroline S Blaum
- Division of Geriatrics, New York University Langone Medical Center, New York, NY
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17
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Miller AL, Min LC, Diehl KM, Cron DC, Chan CL, Sheetz KH, Terjimanian MN, Sullivan JA, Palazzolo WC, Wang SC, Hall KE, Englesbe MJ. Analytic morphomics corresponds to functional status in older patients. J Surg Res 2014; 192:19-26. [PMID: 25015750 PMCID: PMC4188716 DOI: 10.1016/j.jss.2014.06.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [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: 02/23/2014] [Revised: 05/24/2014] [Accepted: 06/04/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Older patients account for nearly half of the United States surgical volume, and age alone is insufficient to predict surgical fitness. Various metrics exist for risk stratification, but little work has been done to describe the association between measures. We aimed to determine whether analytic morphomics, a novel objective risk assessment tool, correlates with functional measures currently recommended in the preoperative evaluation of older patients. MATERIALS AND METHODS We retrospectively identified 184 elective general surgery patients aged >70 y with both a preoperative computed tomography scan and Vulnerable Elderly Surgical Pathways and outcomes Assessment within 90 d of surgery. We used analytic morphomics to calculate trunk muscle size (or total psoas area [TPA]) and univariate logistic regression to assess the relationship between TPA and domains of geriatric function mobility, basic and instrumental activities of daily living (ADLs), and cognitive ability. RESULTS Greater TPA was inversely correlated with impaired mobility (odds ratio [OR] = 0.46, 95% confidence interval [CI] 0.25-0.85, P = 0.013). Greater TPA was associated with decreased odds of deficit in any basic ADLs (OR = 0.36 per standard deviation unit increase in TPA, 95% CI 0.15-0.87, P <0.03) and any instrumental ADLs (OR = 0.53, 95% CI 0.34-0.81; P <0.005). Finally, patients with larger TPA were less likely to have cognitive difficulty assessed by Mini-Cog scale (OR = 0.55, 95% CI 0.35-0.86, P <0.01). Controlling for age did not change results. CONCLUSIONS Older surgical candidates with greater trunk muscle size, or greater TPA, are less likely to have physical impairment, cognitive difficulty, or decreased ability to perform daily self-care. Further research linking these assessments to clinical outcomes is needed.
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Affiliation(s)
- Ashley L Miller
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Lillian C Min
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan; VA Ann Arbor Healthcare System and the Geriatric Research Education Clinical Center (GRECC), Ann Arbor, Michigan
| | - Kathleen M Diehl
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - David C Cron
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Chiao-Li Chan
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - June A Sullivan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Stewart C Wang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Karen E Hall
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan; VA Ann Arbor Healthcare System and the Geriatric Research Education Clinical Center (GRECC), Ann Arbor, Michigan
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Holmes HM, Min LC, Yee M, Varadhan R, Basran J, Dale W, Boyd CM. Rationalizing prescribing for older patients with multimorbidity: considering time to benefit. Drugs Aging 2014; 30:655-66. [PMID: 23749475 DOI: 10.1007/s40266-013-0095-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Given the growing number of older adults with multimorbidity who are prescribed multiple medications, clinicians need to prioritize which medications are most likely to benefit and least likely to harm an individual patient. The concept of time to benefit (TTB) is increasingly discussed in addition to other measures of drug effectiveness in order to understand and contextualize the benefits and harms of a therapy to an individual patient. However, how to glean this information from available evidence is not well established. The lack of such information for clinicians highlights a critical need in the design and reporting of clinical trials to provide information most relevant to decision making for older adults with multimorbidity. We define TTB as the time until a statistically significant benefit is observed in trials of people taking a therapy compared to a control group not taking the therapy. Similarly, time to harm (TTH) is the time until a statistically significant adverse effect is seen in a trial for the treatment group compared to the control group. To determine both TTB and TTH, it is critical that we also clearly define the benefit or harm under consideration. Well-defined benefits or harms are clinically meaningful, measurable outcomes that are desired (or shunned) by patients. In this conceptual review, we illustrate concepts of TTB in randomized controlled trials (RCTs) of statins for the primary prevention of cardiovascular disease. Using published results, we estimate probable TTB for statins with the future goal of using such information to improve prescribing decisions for individual patients. Knowing the relative TTBs and TTHs associated with a patient's medications could be immensely useful to a clinician in decision making for their older patients with multimorbidity. We describe the challenges in defining and determining TTB and TTH, and discuss possible ways of analyzing and reporting trial results that would add more information about this aspect of drug effectiveness to the clinician's evidence base.
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Affiliation(s)
- Holly M Holmes
- Department of General Internal Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA.
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Min LC, Reuben DB, Adams J, Shekelle PG, Ganz DA, Roth CP, Wenger NS. Does better quality of care for falls and urinary incontinence result in better participant-reported outcomes? J Am Geriatr Soc 2011; 59:1435-43. [PMID: 21806560 DOI: 10.1111/j.1532-5415.2011.03517.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether delivery of better quality of care for urinary incontinence (UI) and falls is associated with better participant-reported outcomes. DESIGN Retrospective cohort study. SETTING Assessing Care of Vulnerable Elders Study 2 (ACOVE-2). PARTICIPANTS Older (≥ 75) ambulatory care participants in ACOVE-2 who screened positive for UI (n = 133) or falls or fear of falling (n=328). MEASUREMENTS Composite quality scores (percentage of quality indicators (QIs) passed per participant) and change in Incontinence Quality of Life (IQOL, range 0-100) or Falls Efficacy Scale (FES, range 10-40) scores were measured before and after care was delivered (mean 10 months). Because the treatment-related falls QIs were measured only on patients who received a physical examination, an alternative Common Pathway QI (CPQI) score was developed that assigned a failing score for falls treatment to unexamined participants. RESULTS Each 10% increment in receipt of recommended care for UI was associated with a 1.4-point improvement in IQOL score (P = .01). The original falls composite quality-of-care score was unrelated to FES, but the new CPQI scoring method for falls quality of care was related to FES outcomes (+0.4 points per 10% increment in falls quality, P = .01). CONCLUSION Better quality of care for falls and UI was associated with measurable improvement in participant-reported outcomes in less than 1 year. The connection between process and outcome required consideration of the interdependence between diagnosis and treatment in the falls QIs. The link between process and outcome demonstrated for UI and falls underscores the importance of improving care in these areas.
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Affiliation(s)
- Lillian C Min
- Division of Geriatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA.
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Wenger NS, Roth CP, Shekelle PG, Young RT, Solomon DH, Kamberg CJ, Chang JT, Louie R, Higashi T, MacLean CH, Adams J, Min LC, Ransohoff K, Hoffing M, Reuben DB. A practice-based intervention to improve primary care for falls, urinary incontinence, and dementia. J Am Geriatr Soc 2009; 57:547-55. [PMID: 19175441 DOI: 10.1111/j.1532-5415.2008.02128.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether a practice-based intervention can improve care for falls, urinary incontinence, and cognitive impairment. DESIGN Controlled trial. SETTING Two community medical groups. PARTICIPANTS Community-dwelling patients (357 at intervention sites and 287 at control sites) aged 75 and older identified as having difficulty with falls, incontinence, or cognitive impairment. INTERVENTION Intervention and control practices received condition case-finding, but only intervention practices received a multicomponent practice-change intervention. MEASUREMENTS Percentage of quality indicators satisfied measured using a 13-month medical record abstraction. RESULTS Before the intervention, the quality of care was the same in intervention and control groups. Screening tripled the number of patients identified as needing care for falls, incontinence, or cognitive impairment. During the intervention, overall care for the three conditions was better in the intervention than the control group (41%, 95% confidence interval (CI)=35-46% vs 25%, 95% CI=20-30%, P<.001). Intervention group patients received better care for falls (44% vs 23%, P<.001) and incontinence (37% vs 22%, P<.001) but not for cognitive impairment (44% vs 41%, P=.67) than control group patients. The intervention was more effective for conditions identified by screening than for conditions identified through usual care. CONCLUSION A practice-based intervention integrated into usual clinical care can improve primary care for falls and urinary incontinence, although even with the intervention, less than half of the recommended care for these conditions was provided. More-intensive interventions, such as embedding intervention components into an electronic medical record, will be needed to adequately improve care for falls and incontinence.
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Abstract
OBJECTIVES To investigate whether an abbreviated five-item functional status survey consisting of five activities of daily living (ADLs) reflects changes measured over time in a full 12-item functional status survey. DESIGN Longitudinal evaluation with mean follow-up of 11 months. SETTING Two managed-care organizations in the United States. PARTICIPANTS Four hundred twenty community-dwelling older people at moderate to high risk of death and functional decline enrolled in the Assessing Care of Vulnerable Elders (ACOVE) observational study. MEASURES Number of ADL abilities according to the short (range 0-5) and full functional status surveys (range 0-12); change in function as defined according to a 1-point change in short score and 1- to 2-point change in full survey scores. RESULTS Changes in short functional status survey scores were highly correlated to changes in long survey scores (correlation coefficient=0.88). On average, a 1-point change in the short survey score was associated with a 1.4-point change on the long survey score (P<.001). The short survey correctly classified 93% of those who declined according to the long survey, adjusting for chance agreement (kappa=0.82) and was responsive to decline in function (sensitivity 82-94%, specificity 94-97%, and area under the receiver operating curve 0.91-0.93 for 1- to 2-point decreases in full survey ADL counts). CONCLUSION The short functional status survey is an efficient way to detect changes in functional status in vulnerable older populations for clinical and research purposes.
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Affiliation(s)
- Lillian C Min
- Division of Geriatrics, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA.
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Affiliation(s)
- Lillian C. Min
- David Geffen School of Medicine at UCLA, Department of Medicine
| | - Rajnish Mehrotra
- David Geffen School of Medicine at UCLA, Department of Medicine
- Harbor-UCLA Medical Center, Department of Medicine
| | - Constance Fung
- David Geffen School of Medicine at UCLA, Department of Medicine
- RAND Corporation, Santa Monica
- Veterans Affairs Greater Los Angeles Health Care System
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Min LC, Wenger NS, Fung C, Chang JT, Ganz DA, Higashi T, Kamberg CJ, MacLean CH, Roth CP, Solomon DH, Young RT, Reuben DB. Multimorbidity is Associated With Better Quality of Care Among Vulnerable Elders. Med Care 2007; 45:480-8. [PMID: 17515774 DOI: 10.1097/mlr.0b013e318030fff9] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Older patients with multiple chronic conditions may be at higher risk of receiving poorer overall quality of care compared with those with single or no chronic conditions. Possible reasons include competing guidelines for individual conditions, burden of numerous recommendations, and difficulty implementing treatments for multiple conditions. OBJECTIVES We sought to determine whether coexisting combinations of 8 common chronic conditions (hypertension, coronary artery disease, chronic obstructive pulmonary disease, osteoarthritis, diabetes mellitus, depression, osteoporosis, and having atrial fibrillation or congestive heart failure) are associated with overall quality of care among vulnerable older patients. MATERIALS AND METHODS Using an observational cohort study, we enrolled 372 community-dwelling persons 65 years of age or older who were at increased risk for death or functional decline within 2 years. We included (1) a comprehensive measure (% of quality indicators satisfied) of quality of medical and geriatric care that accounted for patient preference and appropriateness in light of limited life expectancy and advanced dementia, and (2) a measure of multimorbidity, either as a simple count of conditions or as a combination of specific conditions. RESULTS : Multimorbidity was associated with greater overall quality scores: mean proportion of quality indicators satisfied increased from 47% for elders with none of the prespecified conditions to 59% for those with 5 or 6 conditions (P < 0.0001), after controlling for number of office visits. Patients with greater multimorbidity also received care that was better than would be expected based on the specific set of quality indicators they triggered. CONCLUSIONS Among older persons at increased risk of death or functional decline, multimorbidity results in better, rather than worse, quality of care.
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Affiliation(s)
- Lillian C Min
- David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1687, USA.
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Abstract
OBJECTIVES To examine whether the Vulnerable Elders Survey (VES-13) score predicts risk of death and functional decline in vulnerable older adults. DESIGN Longitudinal evaluation with mean follow-up of 11 months (range 8-14 months). SETTING Two managed care organizations in the United States. PARTICIPANTS Four hundred twenty community-dwelling older people identified as having moderate to high risk of death and functional decline based on a VES-13 score of 3 or higher. These older people were enrolled in the Assessing Care of Vulnerable Elders observational study. MEASUREMENTS Baseline: VES-13 score, sex, income, cognitive score, and number of medical diagnoses. OUTCOME MEASURES functional decline and death. RESULTS VES-13 scores strongly predicted death and functional decline (P<.001, area under the receiver operating curve=0.66). The estimated combined risk of death and decline rose with VES-13 score, increasing from 23% for older people with a VES-13 score of 3 to 60% for those with a score of 10. Other measures (sex, comorbidity) were not significant predictors of death or decline over this period after controlling for VES-13 score. CONCLUSION The VES-13 score is useful as a screening tool to detect risk of health deterioration in already vulnerable older populations, and higher scores reflect greater risk over a short follow-up period.
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Affiliation(s)
- Lillian C Min
- Division of Geriatrics and General Internal Medicine and Health Services Researchm University of California, Los Angeles, California 90095, USA.
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Min LC, Reuben DB, MacLean CH, Shekelle PG, Solomon DH, Higashi T, Chang JT, Roth CP, Kamberg CJ, Adams J, Young RT, Wenger NS. Predictors of Overall Quality of Care Provided to Vulnerable Older People. J Am Geriatr Soc 2005; 53:1705-11. [PMID: 16181169 DOI: 10.1111/j.1532-5415.2005.53520.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Prior research shows that the quality of care provided to vulnerable older persons is suboptimal, but little is known about the factors associated with care quality for this group. In this study, the influences of clinical conditions, types of care processes, and sociodemographic characteristics on the quality of care received by vulnerable older people were evaluated. DESIGN Observational cohort study. SETTING Two senior managed care plans. PARTICIPANTS Three hundred sixty-two community-dwelling patients aged 65 and older identified as vulnerable by the Vulnerable Elder Survey (VES-13). MEASUREMENTS OUTCOME VARIABLE patients' observed-minus-expected overall quality score. PREDICTOR VARIABLES types of care processes, types and number of clinical conditions, sex, age, VES-13 score (composite score of function and self-rated health), income, education, mental health status, and number of quality indicators triggered. RESULTS Patients whose conditions required more history-taking, counseling, and medication-prescribing care processes and patients with diabetes mellitus received lower-than-expected quality of care. A greater number of comorbid conditions was associated with higher-than-expected quality of care. Age, sex, VES-13 score, and other sociodemographic variables were not associated with quality of care. CONCLUSION Complexity, vulnerability, and age do not predispose older persons to receive poorer-quality care. In contrast, older patients whose care requires time-consuming processes such as history taking and counseling are at risk for worse quality of care and should be a target for intervention to improve care.
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Affiliation(s)
- Lillian C Min
- Division of Geriatrics, University of California at Los Angeles, Los Angeles, California 90095, USA.
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