Aligning geriatric medicine fellowships with the Program of All-Inclusive Care for the Elderly (PACE)

Geriatric medicine fellowship programs provide comprehensive training to one-year clinical fellows and must demonstrate successful progression of competence among fellows by reporting on 23 milestones to the Accreditation Council for Graduate Medical Education (ACGME). The Program of All-inclusive Care for the Elderly (PACE) is a model of care located throughout the United States and can serve as a training venue for fellows. We surveyed 113 fellowship program directors with a response rate of 42% (n = 48). The purpose of the survey was to assess: (1) familiarity and access to PACE and (2) perceived value of PACE to the fellowship program with regard to training and ability to achieve success in the 23 reporting milestones. Milestones involving communication and team management skills were most consistently identified as very valuable with a PACE clinical rotation. We then convened a focus group of four PACE medical directors who developed a fellowship curriculum for use in training fellows at PACE. We discuss the limitations of our design as well as the opportunities to build on the strengths of that model as a training site for fellows.

Evolution of interdisciplinary geriatric transitions of care on readmission rates

OBJECTIVES

To evaluate the effect of an interdisciplinary transitions of care (TOC) service on readmission rates in a geriatric population.

STUDY DESIGN

Single-center retrospective cohort study of adults 60 years or older discharged from an academic medical center.

METHODS

From July 1, 2013, to February 21, 2016, a total of 4626 patients discharged from 1 hospital, including inpatient, emergency department, observation, and short-stay units, were included. Cases were scheduled for a TOC service with the interdisciplinary team. Controls received usual care at other sites. All-cause 14-, 30-, and 90-day readmission rates between propensity score-matched study groups were evaluated by intention-to-treat (ITT), per-protocol (PP), and as-treated methods.

RESULTS

During the study period, 513 patients were scheduled for at least 1 component of the TOC intervention (ITT group). Of those patients, 215 completed all scheduled visits (PP group). Readmission rate after 30 days demonstrated no difference in the ITT group compared with the control group (12.8% vs 10.7%; P = .215), although it was significantly lower in the PP group in comparison with the control group (12.8% vs 7.9%; P = .042).

CONCLUSIONS

An interdisciplinary team based in a patient-centered medical home improved readmission rates for all patients who completed the intervention (PP group).

Palliative care for patients with end-stage renal disease: approach to treatment that aims to improve quality of life and relieve suffering for patients (and families) with chronic illnesses

Providing end-of-life care to patients suffering from chronic kidney disease (CKD) and/or end-stage renal disease often presents ethical challenges to families and health care providers. However, as the conditions these patients present with are multifaceted in nature, so should be the approach when determining prognosis and treatment strategies for this patient population. Having an interdisciplinary palliative team in place to address any concerns that may arise during conversations related to end-of-life care encourages effective communication between the patient, the family and the medical team. Through the use of a case study, the authors demonstrate how an interdisciplinary palliative team can be used to make decisions that satisfy the patient's and the medical team's desires for end-of-life care.

Potentially inappropriate medication prescribing in outpatient practices: prevalence and patient characteristics based on electronic health records

BACKGROUND

Some older adults receive potentially inappropriate medications (PIMs), increasing their risk for adverse events. A literature search did not find any US multicenter studies that measured the prevalence of PIMs in outpatient practices based on data from electronic health records (EHRs), using both the Beers and Zhan criteria.

OBJECTIVES

The aims of the present study were to compare the prevalence of PIMs using standard drug terminologies at 2 disparate institutions using EHRs and to identify characteristics of elderly patients who have a PIM on their active-medication lists.

METHODS

This cross-sectional study of outpatients' active-medication lists from April 1, 2006, was conducted using data from 2 outpatient primary care settings: Intermountain Healthcare, Salt Lake City, Utah (center 1), and the Cleveland Clinic, Cleveland, Ohio (center 2). Data were included from patients who were aged > or =65 years at the time of the last office visit and had > or =2 documented clinic visits within the previous 2 years. The primary end point was prevalence of PIMs, measured according to the 2002 Beers criteria or the 2001 Zhan criteria.

RESULTS

Data from 61,251 patients were included (36,663 women, 24,588 men; center 1: 37,247 patients; center 2: 24,004). A total of 8693 (23.3%) and 5528 (23.0%) patients at centers 1 and 2, respectively, were documented as receiving a PIM as per the Beers criteria; this difference was not statistically significant. Per the Zhan criteria (P < 0.001), these values were 6036 (16.2%) and 4160 (17.3%). Eight of the most common PIMs were the same at both institutions, with propoxyphene and fluoxetine (once daily) being the most prescribed. Female sex, polypharmacy (> or =6 medications), and multiple primary care visits were significantly associated with PIM prescribing.

CONCLUSIONS

In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations. Female sex, polypharmacy, and number of primary care visits were significantly associated with PIM prescribing. In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations.

Does this patient have primary progressive aphasia?

Primary progressive aphasia (PPA) is a distinct clinical entity in which the patient develops language deficits while other cognitive domains remain relatively preserved until late in the course of the illness. The diagnosis can be relatively clear through an appropriate diagnostic approach based on the history and physical examination. There is no cure, but speech therapy is beneficial in this illness.

Barriers to providing osteoporosis care in skilled nursing facilities: perceptions of medical directors and directors of nursing

OBJECTIVES

The objectives of this study were to identify the barriers to osteoporosis clinical practice guideline use perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in skilled nursing facilities; and to describe differences in the perceptions of MED DIRs and DONs.

DESIGN

The authors conducted a cross-sectional national survey.

PARTICIPANTS

This study consisted of a random national sample of MED DIRs (n = 1300) and DONs (n = 1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-term Care.

MEASUREMENTS

A 24-item survey using a five-point Likert scale was developed. The survey measured agreement to questions in four domains (provider factors, guideline characteristics, patient factors, environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). Response distributions to each item were plotted and differences between MED DIRs and DONs were tested.

RESULTS

Survey response rates were 40% for MED DIRs and 48% for DONs. Respondents strongly agreed that fractures are a problem in their facilities and that osteoporosis guidelines are useful and cost-beneficial (mean responses > or = 4.0). A large proportion of respondents (at least 40% of the sample) identified multiple patient comorbidities, reimbursement issues, length of stay, and regulatory oversight as barriers to providing osteoporosis care. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concerns about bisphosphonate safety were barriers to osteoporosis care. DONs were more likely than MED DIRs to believe that patients and families are concerned about fractures, whereas MED DIRs were more likely to endorse length of stay, staffing issues, and regulatory oversight as influencing treatment decisions. Years of practice and facility size, but not formal geriatrics training, significantly influenced responses.

CONCLUSION

Perceived barriers to implementing osteoporosis guidelines differ between facilities and between MED DIRs and DONs. Identification of these barriers could facilitate quality improvement initiatives and improve the quality of osteoporosis care.

Barriers to providing osteoporosis care in skilled nursing facilities: perceptions of medical directors and directors of nursing

OBJECTIVES

The objectives of this study were to identify the barriers to osteoporosis clinical practice guideline use perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in skilled nursing facilities; and to describe differences in the perceptions of MED DIRs and DONs.

DESIGN

The authors conducted a cross-sectional national survey.

PARTICIPANTS

This study consisted of a random national sample of MED DIRs (n=1300) and DONs (n=1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-term Care.

MEASUREMENTS

A 24-item survey using a five-point Likert scale was developed. The survey measured agreement to questions in four domains (provider factors, guideline characteristics, patient factors, environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). Response distributions to each item were plotted and differences between MED DIRs and DONs were tested.

RESULTS

Survey response rates were 40% for MED DIRs and 48% for DONs. Respondents strongly agreed that fractures are a problem in their facilities and that osteoporosis guidelines are useful and cost-beneficial (mean responses > or = 4.0). A large proportion of respondents (at least 40% of the sample) identified multiple patient comorbidities, reimbursement issues, length of stay, and regulatory oversight as barriers to providing osteoporosis care. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concerns about bisphosphonate safety were barriers to osteoporosis care. DONs were more likely than MED DIRs to believe that patients and families are concerned about fractures, whereas MED DIRs were more likely to endorse length of stay, staffing issues, and regulatory oversight as influencing treatment decisions. Years of practice and facility size, but not formal geriatrics training, significantly influenced responses.

CONCLUSION

Perceived barriers to implementing osteoporosis guidelines differ between facilities and between MED DIRs and DONs. Identification of these barriers could facilitate quality improvement initiatives and improve the quality of osteoporosis care.

The HORIZON Recurrent Fracture Trial: design of a clinical trial in the prevention of subsequent fractures after low trauma hip fracture repair

OBJECTIVE

To present the novel design of a trial testing the safety and efficacy of a yearly bisphosponate, zoledronic acid, in preventing new clinical fractures in patients with recent low trauma hip fracture repair.

RESEARCH DESIGN AND METHODS

Randomized, placebo-controlled, triple-blind study. One hundred and fifteen clinical centers worldwide are recruiting approximately 1714 subjects aged 50 years and over (no upper age limit, median age of enrolled subjects to date 79 years) who have undergone surgical repair of a low trauma hip fracture in the preceding 90 days. Patients will be assigned at random to an intervention group (5 mg zoledronic acid intravenously yearly) or a control group (placebo infusion yearly). Both groups receive a loading dose of Vitamin D2 or D3 IM or orally, followed by 800-1200 IU Vitamin D and 1000-1500 mg elemental calcium orally on a daily basis. Concomitant therapy with calcitonin, hormone replacement therapy, selective estrogen receptor modulators, tibolone, and external hip protectors are allowed.

MAIN OUTCOME MEASURES

The primary endpoint is subsequent skeletal fractures as adjudicated by a clinical endpoints committee blinded to intervention status. Secondary outcomes include delayed hip fracture healing, changes in bone mineral density, and health resource utilization. Subjects will be recruited over a 3-4 year period and will be followed until 211 primary endpoints are accrued and adjudicated.

CONCLUSIONS

This randomized clinical trial is novel among osteoporosis therapies as it (1). targets hip fracture patients, a previously understudied group, and (2). uses only clinically evident fractures as the primary outcome. Ethical and practical considerations in studying this frail population are discussed.

Osteoporosis considerations in the frail elderly

Osteoporosis is a growing public health problem throughout the world, in part because of the increasing numbers of people living beyond the age of 65 years. Skeletal fractures are the clinical manifestation of the disease, with older patients the most severely affected. Conditions associated with frailty such as falls and reduced muscle strength likely contribute to fractures, causing substantial mortality, morbidity, and economic cost. Screening guidelines for osteoporosis have been issued recently and take into account multiple risk factors for this condition. Falls are the chief mechanism by which osteoporotic fractures occur. Nonpharmacologic interventions for osteoporosis mainly address fall and frailty prevention, whereas pharmacologic interventions target bone loss through decreasing bone resorption, increasing bone formation, or a combination of both processes. Although guidelines for intervention strategies are in flux, it is now suggested that absolute fracture risk rather than diagnostic thresholds be used to determine the timing for therapeutic intervention. Individual risks and benefits of therapies need to be considered before choosing a therapeutic regimen.

Genetic manipulation of fibrinogen and fibrinolysis in mice

Vascular integrity is maintained by a sophisticated system of circulating and cell associated hemostatic factors that control local platelet deposition, the conversion of soluble fibrinogen to an insoluble fibrin polymer, and the dissolution of fibrin matrices. However, hemostatic factors are likely to be biologically more important than merely maintaining vascular patency and controlling blood loss. Specific hemostatic factors have been associated with a wide spectrum of physiological processes, including development, reproduction, tissue remodeling, wound repair, angiogenesis, and the inflammatory response. Similarly, it has been proposed that hemostatic factors are important determinants of a variety of pathological processes, including vessel wall disease, tumor dissemination, infectious disease, and inflammatory diseases of the joint, lung, and kidney. The development of gene targeted mice either lacking or expressing modified forms of selected hemostatic factors has provided a valuable opportunity to test prevailing hypotheses regarding the biological roles of key coagulation and fibrinolytic system components in vivo. Genetic analyses of fibrin(ogen) and its interacting factors in transgenic mice have proven to be particularly illuminating, often challenging long standing concepts. This review summarizes the key findings made in recent studies of gene targeted mice with single and combined deficits in fibrinogen and fibrinolytic factors. Studies illustrating the role and interplay of these factors in disease progression are highlighted.

Impaired platelet aggregation and sustained bleeding in mice lacking the fibrinogen motif bound by integrin alpha IIb beta 3

Blood loss at sites of vascular rupture is controlled by the adhesion and aggregation of platelets and the formation of an insoluble fibrin matrix. Fibrinogen is considered to be critical in these processes by both providing an abundant dimeric ligand for alpha IIb beta 3-mediated platelet aggregation, and serving as the fundamental building block of the fibrin polymer. To establish an in vivo model system to examine in detail the importance of alpha IIb beta 3-fibrinogen interactions in platelet function, hemostasis, response to injury and vasoocclusive disease, and to test the prevailing hypothesis that the C-terminal segment of the fibrinogen gamma chain is essential for alpha IIb beta 3 binding, we have used gene-targeting technology in mice to eliminate the last five residues (QAGDV) from the gamma chain. Mice homozygous for the modified gamma chain gene (gamma delta 5/gamma delta 5) displayed a generally normal hematological profile, including normal platelet count, plasma fibrinogen level, clotting time and fibrin crosslinking. However, both gamma delta 5-fibrinogen binding to alpha IIb beta 3 and platelet aggregation were highly defective. Remarkably, another alpha IIb beta 3-dependent process, clot retraction, was unaffected by the gamma delta 5 mutation. Despite the preservation of clotting function, gamma delta 5/gamma delta 5 mice were unable to control blood loss following a surgical challenge and occasionally developed fatal neonatal bleeding events.

Resolution of spontaneous bleeding events but failure of pregnancy in fibrinogen-deficient mice

To explore the role of the key coagulation factor, fibrinogen, in development, hemostasis, wound repair, and disease pathogenesis, we disrupted the fibrinogen A alpha chain gene in mice. Homozygous, A alpha chain-deficient (A alpha-/-) mice are born normal in appearance, and there is no evidence of fetal loss of these animals based on the Mendelian pattern of transmission of the mutant A alpha chain allele. All of the component chains of fibrinogen (A alpha, B beta, and gamma) are immunologically undetectable in the circulation of both neonatal and adult A alpha-/- mice, and blood samples fail to either clot or support platelet aggregation in vitro. Overt bleeding events develop shortly after birth in approximately 30% of A alpha-/- mice, most frequently in the peritoneal cavity, skin, and soft tissues around joints. Remarkably, most newborns displaying signs of bleeding ultimately control the loss of blood, clear the affected tissues, and survive the neonatal period. Juveniles and young adult A alpha-/- mice are predisposed to spontaneous fatal abdominal hemorrhage, but long-term survival is variable and highly dependent on genetic background. The periodic rupture of ovarian follicles in breeding-age A alpha-/- females does not appear to significantly diminish life expectancy relative to males; however, pregnancy uniformly results in fatal uterine bleeding around the tenth day of gestation. Microscopic analysis of spontaneous lesions found in A alpha-/- mice suggests that fibrin(ogen) plays a fundamental role in the organization of cells at sites of injury.

A conserved TATA-less proximal promoter drives basal transcription from the urokinase-type plasminogen activator receptor gene

The urokinase-type plasminogen activator receptor (uPAR) focuses at the cell surface the activation of pro-uPA and, hence, the formation of plasmin, thus enhancing directional extracellular proteolysis. To characterize the transcriptional regulatory mechanisms that control receptor expression, we have cloned an uPAR DNA segment containing upstream regulatory sequences from both the human and murine genomes. We report that a proximal promoter, contained within 180 bp from the major transcription start sites of the human uPAR gene, drives basal transcription. This region lacks TATA and CAAT boxes and contains relatively GC-rich proximal sequences. A subregion of this sequence, highly conserved between human and murine genes, contains most of the promoter activity and is specifically bound by HeLa nuclear proteins, one of which belongs to the SP1 class.

The receptor for urokinase-type plasminogen activator is not essential for mouse development or fertility

The urokinase-type plasminogen activator receptor (uPAR) gene was disrupted in mice in order to explore the role of cell surface-associated plasminogen activation in development and hemostasis. Homozygous, uPAR-/- mice were born and survived to adulthood with no overt phenotypic abnormalities. There was no indication of loss of fetal animals based on the Mendelian pattern of transmission of the mutant uPAR gene. uPAR-/- mice carried no detectable uPAR in lung, spleen, and other tissues when measured both immunologically by Western blot analysis and functionally by ligand cross-linking analyses. In addition, activated peritoneal macrophages collected from uPAR-/- mice failed to promote plasminogen activation in vitro. The loss of the receptor also resulted in a redistribution of uPA in some tissues but had no impact on pro-uPA activation in the urogenital tract. Thus, in the absence of other challenging factors such as infection, injury, or other functional deficits, uPAR deficiency does not compromise fertility, development, or hemostasis. These mice provide a means to test the proposed function of uPA/uPAR in wound repair, atherogenesis, and tumor cell invasion in vivo.

The murine urokinase-type plasminogen activator receptor gene

The murine urokinase-type plasminogen activator receptor (uPAR) gene has been isolated and its complete nucleotide sequence established. The gene is organized into seven exons comprising 9.5% of the 13,207-base pair region that spans the interval between the transcription initiation and polyadenylation sites. The region upstream of the transcription initiation site lacks TATA- or CCAAT-like elements but is flanked by a G+C-rich region, which contains a number of potential regulatory elements including Sp1 and AP1 binding motifs. The close association of both Sp1 and AP1 sites within the proximal promoter region is consistent with the observation that the murine uPAR gene is inducible by phorbol esters. The major functional domains of the encoded protein, including the signal peptide, three cysteine-rich internal repeats, and the glycolipid anchor attachment motif, are encoded by separate exons. Based on the organization of the murine uPAR gene and the distribution of protein domains within the exons in the Ly-6 family of genes, it appears that the uPAR gene evolved secondarily to two internal duplication events within a Ly-6-like ancestral gene. The cloned and sequenced murine uPAR gene will be a valuable tool in understanding the regulation and biological roles of uPAR in that it will permit detailed studies of gene expression and uPAR-dependent processes in vitro, as well as the generation of both gain-of-function and loss-of-function mutants in transgenic mice.