RESUMO
"Gluing" together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: 1) the US's historical fee for service (FFS) reimbursement system; 2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and 3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: 1) local political advocacy to implement health policy legislation; 2) expand geriatric physician and health professional workforce by nontraditional means; and 3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.
Assuntos
Atenção à Saúde , Geriatria , Humanos , Idoso , Pessoal de Saúde , Política de SaúdeRESUMO
Religion and spirituality have long been considered important social determinants of human health, and there exists an extensive body of research to support such. End-of-life (EOL) may raise complex questions for individuals about religious and spiritual (R/S) values guiding advance care planning (ACP) and EOL care decisions, including the provision of spiritual care. This commentary will review the history and current national trends of ACP activities for EOL, principally within the United States. It will describe the relationship of religious variables and the attributes of selected research instruments used to study religious variables on ACP and EOL preferences. The review also summarizes unique ACP challenges for patients with neurocognitive disorders and severe mental illness. Findings disclose that higher levels of religiosity, reliance on religious coping, conservative faith traditions, and "belief in God's control over life's length and divine intervention have lower levels of ACP and more intensive EOL care preferences, although the provision of spiritual spiritual care at EOL mitigates intensive EOL care. Based upon the curated evidence, we propose an epistemological justification to consider "faith" as a separately defined religious variable in future ACP and EOL research. This review is relevant to geriatric psychiatrists and gerontological health care professionals, as they may be part of multidisciplinary palliative care teams; provide longitudinal care to patients with neurocognitive disorders and severe mental illness; and may provide diagnostic, emotional, and therapeutic services for patients and families who may struggle with EOL care decisions.
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Planejamento Antecipado de Cuidados , Cuidados Paliativos na Terminalidade da Vida , Assistência Terminal , Idoso , Humanos , Cuidados Paliativos , Espiritualidade , Assistência Terminal/psicologia , Estados UnidosRESUMO
BACKGROUND: Several American universities have experienced COVID-19 outbreaks, risking the health of their students, employees, and local communities. Such large outbreaks have drained university resources and forced several institutions to shift to remote learning and send students home, further contributing to community disease spread. Many of these outbreaks can be attributed to the large numbers of active infections returning to campus, alongside high-density social events that typically take place at the semester start. In the absence of effective mitigation measures (e.g., high-frequency testing), a phased return of students to campus is a practical intervention to minimize the student population size and density early in the semester, reduce outbreaks, preserve institutional resources, and ultimately help mitigate disease spread in communities. METHODS: We develop dynamic compartmental SARS-CoV-2 transmission models to assess the impact of a phased reopening, in conjunction with pre-arrival testing, on minimizing on-campus outbreaks and preserving university resources (measured by isolation bed capacity). We assumed an on-campus population of N = 7500, 40% of infected students require isolation, 10 day isolation period, pre-arrival testing removes 90% of incoming infections, and that phased reopening returns one-third of the student population to campus each month. We vary the disease reproductive number (Rt) between 1.5 and 3.5 to represent the effectiveness of alternative mitigation strategies throughout the semester. RESULTS: Compared to pre-arrival testing only or neither intervention, phased reopening with pre-arrival testing reduced peak active infections by 3 and 22% (Rt = 1.5), 22 and 29% (Rt = 2.5), 41 and 45% (Rt = 3.5), and 54 and 58% (improving Rt), respectively. Required isolation bed capacity decreased between 20 and 57% for values of Rt ≥ 2.5. CONCLUSION: Unless highly effective mitigation measures are in place, a reopening with pre-arrival testing substantially reduces peak number of active infections throughout the semester and preserves university resources compared to the simultaneous return of all students to campus. Phased reopenings allow institutions to ensure sufficient resources are in place, improve disease mitigation strategies, or if needed, preemptively move online before the return of additional students to campus, thus preventing unnecessary harm to students, institutional faculty and staff, and local communities.
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COVID-19 , Universidades , Surtos de Doenças/prevenção & controle , Humanos , SARS-CoV-2 , EstudantesRESUMO
Never has there been a more pressing time for the American Association for Geriatric Psychiatry (AAGP) to articulate a unified strategy to meet the challenges of our aging world. To this end, this report summarizes an AAGP leadership meeting that reviewed the results from a recent membership survey and launched a strategic planning process on behalf of AAGP members and stakeholders. This meeting was the first step in drafting a blueprint for the future that may serve as our guide in the context of finite resources to meet the infinitely complex and growing need for education, research, public advocacy, and clinical practice support. The following report serves to invite our valued colleagues to provide feedback and actively participate in defining our mission. Among the outcomes of the planning session, the following aspirations were identified by the participants 1) assert the AAGP as the "go to" organization for all things related to geriatric mental health, 2) prioritize activities that enhance the inclusivity/diversity of membership, and 3) collaborate across disciplines focused on geriatric mental health. From this initial framework, the group developed four general themes to guide AAGP's strategic future: 1) collaboration, 2) advocacy, 3) inclusivity, 4) high purpose. Inclusivity was further defined as encompassing growth, return on investment, and workforce development. Higher purpose was further defined as encompassing engagement, purpose, branding, communication, and expertise. The AAGP affirmed its commitment to serving the needs of its members and widening its scope of impact in view of staggering demands for better access to geriatric mental healthcare.
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Psiquiatria Geriátrica/tendências , Publicações Periódicas como Assunto , Sociedades Médicas , Planejamento Estratégico , HumanosAssuntos
Demência , Política de Saúde , Serviços de Assistência Domiciliar , Humanos , Demência/economia , Demência/terapia , Serviços de Assistência Domiciliar/economia , Política de Saúde/economia , Cuidadores/economia , Família , Serviços de Saúde Comunitária/economia , Custos de Cuidados de Saúde/estatística & dados numéricosRESUMO
The Institute of Medicine estimated that by 2030, from 10.1 to 14.4 million Americans aged 65 years or older will have mental health or substance use disorders. This article reviews the history and current status of training, certification, and practice in geriatric psychiatry against the backdrop of this "silver tsunami." The American Board of Psychiatry and Neurology (ABPN) administered the first subspecialty examination in geriatric psychiatry in 1991, and through 2015 3,329 certificates were awarded. The Accreditation Council for Graduate Medical Education approved the training requirements in 1993. After a surge in programs and fellows, the numbers appear to have stabilized at about 57 programs and 60-65 trainees per year with fewer than half of the positions filled each year. The majority of graduates seeks and obtains ABPN certification, and the majority of those who were fellowship trained have maintained certification. Despite the unprecedented demand for mental health services for older adults, it must be acknowledged that not enough geriatric psychiatrists can be prepared to meet the needs of an aging U.S. POPULATION: Strategies for addressing the shortage are discussed, including undertaking subspecialty training in the fourth year of psychiatry training, increasing the time devoted to the care of older adults in undergraduate and graduate medical education, and developing alternative training pathways such as mini-fellowships. It is not clear whether more favorable Medicare reimbursement rates for those certified in geriatric psychiatry would increase the numbers seeking fellowship training.
Assuntos
Certificação/tendências , Psiquiatria Geriátrica/educação , Especialização/tendências , Bolsas de Estudo , Psiquiatria Geriátrica/tendências , Humanos , Recursos HumanosRESUMO
"Gluing" together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: (1) the US's historical fee for service (FFS) reimbursement system; (2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and (3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: (1) local political advocacy to implement health policy legislation; (2) expand geriatric physician and health professional workforce by nontraditional means; and (3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.
Assuntos
Atenção à Saúde , Geriatria , Humanos , Idoso , Pessoal de Saúde , Política de SaúdeRESUMO
The great health paradox is that the least expensive and most effective public health measures available for addressing the COVID-19 pandemic-and other society-wide health challenges-have long been ignored and rejected in the United States in favor of more expensive and personalized care. The U.S. medical system is being overwhelmed in part because of this paradox. The authors argue that the country has invested excessively in acute care medical technology while investing insufficiently in its public health infrastructure. In this Invited Commentary, the authors recommend 5 steps that academic medicine should take to increase emphasis on and understanding of public health interventions to address society's health problems: (1) incorporate problem-based learning experiences in the medical school curriculum and community-based clinical rotations in public health departments, (2) better integrate schools of public health and schools of medicine, (3) encourage physicians to pursue public health careers, (4) educate the public about strategies for decreasing chronic illnesses, and (5) increase collaboration with colleagues around the world to identify and track outbreaks.
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COVID-19 , Saúde Pública , COVID-19/epidemiologia , COVID-19/prevenção & controle , Currículo , Humanos , Pandemias/prevenção & controle , Faculdades de Medicina , Estados UnidosRESUMO
Objective: Assessment of predictive values of clinical symptoms for COVID-19 diagnosis in young adults. Participants: Nonresidential university students (ages 18-25) participating in surveillance testing and mandatory symptom survey between 9/9/2020 and 11/25/2020. Methods: Retrospective study of test results and symptom survey data. Results: Among 6,489 individuals, 288 (4.4%) tested positive for COVID-19, 90 (31.3%) of whom reported symptoms. COVID-19 prevalence among individuals reporting and not reporting symptoms was 17.2% and 3.3%, respectively. The four symptoms with highest positive predictive values (PPVs) were smell/taste loss (PPV = 38.5%), chills (PPV = 31.5%), muscle/joint pain (PPV = 26.0%), and fever (PPV = 25.9%). Conclusions: Institutions should emphasize COVID-19 risk for highly predictive symptoms in public health messaging to inform individuals on when to seek testing or self-isolation. However, low COVID-19 diagnostic accuracy of clinical symptoms and the high pre-symptomatic/asymptomatic rate (69%) highlight the limitations of voluntary testing strategies employed by higher education institutions during the original strain of SARS-CoV-2.
RESUMO
OBJECTIVE: this article reviews the current status and recent trends in the American Board of Psychiatry and Neurology (ABPN) psychiatric subspecialties and discusses the implications of those trends as well as several key questions whose answers may well determine subspecialty viability. METHODS: data are presented on specialty and subspecialty programs; graduates; and ABPN certification candidates and diplomates drawn from several sources, including the records of the ABPN, the websites of the Accreditation Council for Graduate Medical Education and the American Medical Association, and the annual medical education issues of JAMA. RESULTS: fewer than half of psychiatry graduates pursue subspecialty training. While most recent specialty graduates attempt to become certified by the ABPN, many subspecialists elect not to do so. There have been recent decreases in the number of fellowship programs and trainees in geriatric psychiatry and addiction psychiatry. The pass rates for fellowship graduates are superior to those for the "grandfathers" in all of the newer psychiatric subspecialties. Lower percentages of subspecialists than specialists participate in maintenance of certification, and maintenance of certification pass rates are high. CONCLUSION: the initial interest in training and certification in some of the ABPN subspecialties appears to have slowed, and the long-term viability of those subspecialties may well depend on the answers to a number of complicated social, economic, and political questions in the new health care era.
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Neurologia/educação , Psiquiatria/educação , Especialização , Participação da Comunidade , Coleta de Dados , Economia , Educação , Educação de Pós-Graduação em Medicina , Humanos , Política , Desenvolvimento de Programas , Especialização/tendências , Conselhos de Especialidade Profissional/tendências , Estados UnidosRESUMO
BACKGROUND: Despite severe outbreaks of COVID-19 among colleges and universities across the USA during the Fall 2020 semester, the majority of institutions did not routinely test students. While high-frequency repeated testing is considered the most effective strategy for disease mitigation, most institutions do not have the necessary infrastructure or funding for implementation. Therefore, alternative strategies for testing the student population are needed. Our study detailed the implementation and results of testing strategies to mitigate SARS-CoV-2 spread on a university campus, and we aimed to assess the relative effectiveness of the different testing strategies. METHODS: For this retrospective cohort study, we included 6273 on-campus students arriving to a large public university in the rural USA (Clemson, SC, USA) for in-person instruction in the Fall 2020 semester (Sept 21 to Nov 25). Individuals arriving after Sept 23, those who tested positive for SARS-CoV-2 before Aug 19, and student athletes and band members were not included in this study. We implemented two testing strategies to mitigate SARS-CoV-2 spread during this period: a novel surveillance-based informative testing (SBIT) strategy, consisting of random surveillance testing to identify outbreaks in residence hall buildings or floors and target them for follow-up testing (Sept 23 to Oct 5); followed by a repeated weekly surveillance testing (Oct 6 to Nov 22). Relative changes in estimated weekly prevalence were examined. We developed SARS-CoV-2 transmission models to compare the relative effectiveness of weekly testing (900 daily surveillance tests), SBIT (450 daily surveillance tests), random surveillance testing (450 daily surveillance tests), and voluntary testing (0 daily surveillance tests) on disease mitigation. Model parameters were based on our empirical surveillance data in conjunction with published sources. FINDINGS: SBIT was implemented from Sept 23 to Oct 5, and identified outbreaks in eight residence hall buildings and 45 residence hall floors. Targeted testing of residence halls was 2·03 times more likely to detect a positive case than random testing (95% CI 1·67-2·46). Weekly prevalence was reduced from a peak of 8·7% to 5·6% during this 2-week period, a relative reduction of 36% (95% CI 27-44). Prevalence continued to decrease after implementation of weekly testing, reaching 0·8% at the end of in-person instruction (week 9). SARS-CoV-2 transmission models concluded that, in the absence of SBIT (ie, voluntary testing only), the total number of COVID-19 cases would have increased by 154% throughout the semester. Compared with SBIT, random surveillance testing alone would have resulted in a 24% increase in COVID-19 cases. Implementation of weekly testing at the start of the semester would have resulted in 36% fewer COVID-19 cases throughout the semester compared with SBIT, but it would require twice the number of daily tests. INTERPRETATION: It is imperative that institutions rigorously test students during the 2021 academic year. When high-frequency testing (eg, weekly) is not possible, SBIT is an effective strategy to mitigate disease spread among the student population that can be feasibly implemented across colleges and universities. FUNDING: Clemson University, USA.
Assuntos
Teste para COVID-19 , COVID-19/diagnóstico , COVID-19/prevenção & controle , Programas de Rastreamento/métodos , Universidades , COVID-19/transmissão , Humanos , Estudos Retrospectivos , SARS-CoV-2 , South Carolina/epidemiologiaRESUMO
OBJECTIVE: To estimate the frequency of depressive symptoms and selected psychiatric disorders in the Women's Health Initiative Memory Study (WHIMS) cohort and related them to cognitive syndromes. DESIGN: WHIMS was a randomized, double-blinded, placebo-controlled prevention clinical trial examining whether opposed and unopposed hormone therapy reduced the risk of dementia in healthy postmenopausal women. Participants scoring below a designated cutpoint on a cognitive screener received a comprehensive neuropsychiatric workup and adjudicated outcome of no cognitive impairment, mild cognitive impairment, or probable dementia. PARTICIPANTS: Seven thousand four hundred seventy-nine WHIMS participants between age 65 and 79 years and free of dementia at the time of enrollment in WHIMS. Five hundred twenty-one unique participants contributed complete data required for these analyses. MEASURES: Depressive symptoms were measured with the 15-item Geriatric Depression Scale and the presence of selected psychiatric disorders (major depression, generalized anxiety, and panic and alcohol abuse) was made using the PRIME-MD. RESULTS: The 18% of women had at least one psychiatric disorder with depression being the most common (16%) followed by general anxiety or panic (6%) and alcohol abuse (1%). Depression and the presence of a psychiatric disorder were associated with impaired cognitive status. Participants having a psychiatric disorder were more than twice as likely to be diagnosed with cognitive impairment as those with no psychiatric disorder (odds ratio = 2.06, 95% confidence interval = 1.17-3.60). Older age, white race, and diabetes were also associated with cognitive impairment. CONCLUSION: The frequency of a psychiatric disorder is associated with poorer cognitive functioning among older women enrolled in WHIMS. That approximately one in five women had a probable psychiatric disorder, most typically depression, highlights the need for greater detection and treatment efforts in this population.
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Transtornos Cognitivos/epidemiologia , Transtornos Mentais/epidemiologia , Pós-Menopausa/psicologia , Idoso , Transtornos Cognitivos/complicações , Estudos de Coortes , Feminino , Humanos , Transtornos Mentais/complicações , Prevalência , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Saúde da MulherRESUMO
BACKGROUND: The Texas A&M College of Medicine was traditionally a small 2+2 institution where students spent 2 years on one campus for basic science study and 2 years on another campus for clinical study. PURPOSE: To answer calls for an increased physician workforce, we more than doubled our class size and our number of fully matriculating branch campuses. This article describes the 1st full year's experience with expansion. Distance learning was a key part of the experience. METHODS: After extensive planning and pilot study, 1st-year students were fully matriculated at 1 of 2 campuses. Year-end comparisons were made on students' achievement and a satisfaction questionnaire. RESULTS: No statistically significant differences were found on any achievement measures and only several questionnaire items. CONCLUSIONS: Expansion from the 2+2 system to 2 fully-matriculating campuses with a larger student body was successful during its 1st year. Some persistent problems and planned solutions are reported.
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Currículo , Educação a Distância/métodos , Educação Médica/métodos , Faculdades de Medicina/organização & administração , Educação Médica/organização & administração , Escolaridade , Humanos , Modelos Educacionais , Satisfação Pessoal , Projetos Piloto , Inquéritos e Questionários , TexasRESUMO
The coronavirus (COVID-19) pandemic is having profound effects on the lives and well-being of the world's population. All levels of the nation's public health and health care delivery systems are rapidly adjusting to secure the health infrastructure to manage the pandemic in the United States. As the nation's safety net health care systems, academic medical centers (AMCs) are vital clinical and academic resources in managing the pandemic. COVID-19 may also risk the financial underpinnings of AMCs because their cost structures are high, and they may have incurred large amounts of debt over the last decade as they expanded their clinical operations and facilities. This Invited Commentary reviews existing data on AMC debt levels; summarizes relief provided in the Coronavirus Aid, Relief, and Economic Security Act; and suggests policy options to help mitigate risk.
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Centros Médicos Acadêmicos/economia , Betacoronavirus , Infecções por Coronavirus/economia , Pandemias/economia , Pneumonia Viral/economia , Saúde Pública/economia , COVID-19 , Atenção à Saúde/economia , Humanos , SARS-CoV-2 , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: In a previously published study, the authors conceptualized neuropsychiatric symptoms in Alzheimer disease (AD) patients as distinct symptom profiles with differential outcomes. In the present study, our aim was to further examine the validation of the classification by considering its concurrent validity on caregiver burden. METHOD: As described previously, neuropsychiatric symptoms, as assessed by the Neuropsychiatric Inventory, in 122 patients with AD were categorized, using cluster analysis. The presence as well as the severity and frequency of symptoms were both used in the classification. After the classification, group differences in caregiver burden, as measured by Screen for Caregiver Burden, were tested using analysis of covariance. The effects of important covariates, such as functional impairment, comorbid medical conditions, parkinsonism, age, and cognitive functioning, were examined. RESULTS: Based on the presence of symptoms, subgroups differed in the level of caregiver distress in that caregivers of the "minimally symptomatic" and the "affective/apathetic" subgroups experienced less distress than the caregivers of the "highly symptomatic" subgroup. Based on the severity and frequency of symptoms, subgroups differed in such a way that caregivers of the "minimally symptomatic" and the "predominantly apathetic" subgroups endorsed less distress than the caregivers of the "affective" and the "highly symptomatic" subgroups. CONCLUSION: Neuropsychiatric subgroups were able to differentially predict caregiver burden. The findings appear to lend further support to the validity of classifying neuropsychiatric symptoms in AD patients using cluster analysis.