The interagency care team: A new model to integrate social and medical care for older adults in primary care.

To integrate management of social drivers of health with complex clinical needs of older adults, we connected patients aged 60 and above from primary care practices with a nurse practitioner (NP) led Interagency Care Team (ICT) of geriatrics providers and community partners via electronic consult. The NP conducted a geriatric assessment via telephone, then the team met to determine recommendations. Thirteen primary care practices referred 123 patients (median age = 76) who had high rates of emergency department use and hospitalization (28.9% and 17.4% respectively). Issues commonly identified included medication management (84%), personal safety (72%), disease management (69%), food insecurity (63%), and cognitive decline (53%). Referring providers expressed heightened awareness of older adults' social needs and high satisfaction with the program. The ICT is a scalable model of care that connects older adults with complex care needs to geriatrics expertise and community services through partnerships with primary care providers.

Developing a Real-Time Electroencephalogram-Guided Anesthesia-Management Curriculum for Educating Residents: A Single-Center Randomized Controlled Trial.

BACKGROUND: Different anesthetic drugs and patient factors yield unique electroencephalogram (EEG) patterns. Yet, it is unclear how best to teach trainees to interpret EEG time series data and the corresponding spectral information for intraoperative anesthetic titration, or what effect this might have on outcomes. METHODS: We developed an electronic learning curriculum (ELC) that covered EEG spectrogram interpretation and its use in anesthetic titration. Anesthesiology residents at a single academic center were randomized to receive this ELC and given spectrogram monitors for intraoperative use versus standard residency curriculum alone without intraoperative spectrogram monitors. We hypothesized that this intervention would result in lower inhaled anesthetic administration (measured by age-adjusted total minimal alveolar concentration [MAC] fraction and age-adjusted minimal alveolar concentration [aaMAC]) to patients ≥60 old during the postintervention period (the primary study outcome). To study this effect and to determine whether the 2 groups were administering similar anesthetic doses pre- versus postintervention, we compared aaMAC between control versus intervention group residents both before and after the intervention. To measure efficacy in the postintervention period, we included only those cases in the intervention group when the monitor was actually used. Multivariable linear mixed-effects modeling was performed for aaMAC fraction and hospital length of stay (LOS; a non-prespecified secondary outcome), with a random effect for individual resident. A multivariable linear mixed-effects model was also used in a sensitivity analysis to determine if there was a group (intervention versus control group) by time period (post- versus preintervention) interaction for aaMAC. Resident EEG knowledge difference (a prespecified secondary outcome) was compared with a 2-sided 2-group paired t test. RESULTS: Postintervention, there was no significant aaMAC difference in patients cared for by the ELC group (n = 159 patients) versus control group (N = 325 patients; aaMAC difference = -0.03; 95% confidence interval [CI], -0.09 to 0.03; P =.32). In a multivariable mixed model, the interaction of time period (post- versus preintervention) and group (intervention versus control) led to a nonsignificant reduction of -0.05 aaMAC (95% CI, -0.11 to 0.01; P = .102). ELC group residents (N = 19) showed a greater increase in EEG knowledge test scores than control residents (N = 20) from before to after the ELC intervention (6-point increase; 95% CI, 3.50-8.88; P < .001). Patients cared for by the ELC group versus control group had a reduced hospital LOS (median, 2.48 vs 3.86 days, respectively; P = .024). CONCLUSIONS: Although there was no effect on mean aaMAC, these results demonstrate that this EEG-ELC intervention increased resident knowledge and raise the possibility that it may reduce hospital LOS.

A Processed Electroencephalogram-Based Brain Anesthetic Resistance Index Is Associated With Postoperative Delirium in Older Adults: A Dual Center Study.

BACKGROUND: Some older adults show exaggerated responses to drugs that act on the brain. The brain's response to anesthetic drugs is often measured clinically by processed electroencephalogram (EEG) indices. Thus, we developed a processed EEG-based measure of the brain's resistance to volatile anesthetics and hypothesized that low scores on it would be associated with postoperative delirium risk. METHODS: We defined the Duke Anesthesia Resistance Scale (DARS) as the average bispectral index (BIS) divided by the quantity (2.5 minus the average age-adjusted end-tidal minimum alveolar concentration [aaMAC] inhaled anesthetic fraction). The relationship between DARS and postoperative delirium was analyzed in 139 older surgical patients (age ≥65) from Duke University Medical Center (n = 69) and Mt Sinai Medical Center (n = 70). Delirium was assessed by geriatrician interview at Duke, and by research staff utilizing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument at Mt Sinai. We examined the relationship between DARS and delirium and used the Youden index to identify an optimal low DARS threshold (for delirium risk), and its associated 95% bootstrap confidence bounds. We used multivariable logistic regression to examine the relationship between low DARS and delirium risk. RESULTS: The relationship between DARS and delirium risk was nonlinear, with higher delirium risk at low DARS scores. A DARS threshold of 28.755 maximized the Youden index for the association between low DARS and delirium, with bootstrap 95% confidence bounds of 26.18 and 29.80. A low DARS (<28.755) was associated with increased delirium risk in multivariable models adjusting for site (odds ratio [OR] [95% confidence interval {CI}] = 4.30 [1.89-10.01]; P = .001), or site-plus-patient risk factors (OR [95% CI] = 3.79 [1.63-9.10]; P = .003). These associations with postoperative delirium risk remained significant when using the 95% bootstrap confidence bounds for the low DARS threshold (P < .05 for all). Further, a low DARS (<28.755) was associated with delirium risk after accounting for opioid, midazolam, propofol, phenylephrine, and ketamine dosage as well as site (OR [95% CI] = 4.21 [1.80-10.16]; P = .002). This association between low DARS and postoperative delirium risk after controlling for these other medications remained significant (P < .05) when using either the lower or the upper 95% bootstrap confidence bounds for the low DARS threshold. CONCLUSIONS: These results demonstrate that an intraoperative processed EEG-based measure of lower brain anesthetic resistance (ie, low DARS) is independently associated with increased postoperative delirium risk in older surgical patients.

Perioperative Optimization of Senior Health (POSH): A Descriptive Analysis of Cancelled Surgery.

BACKGROUND: Geriatric collaborative care models improve postoperative outcomes for older adults. However, there are limited data exploring how preoperative geriatric assessment may affect surgical cancellations. METHODS: This is a single-center retrospective cohort analysis. Patients enrolled in the Perioperative Optimization of Senior Health (POSH) program from 2011 to 2016 were included. POSH is a collaborative care model between geriatrics, surgery, and anesthesiology. Baseline demographic and medical data were collected during the POSH pre-op appointment. Patients who attended a POSH pre-op visit but did not have surgery were identified, and a chart review was performed to identify reasons for surgical cancellation. Baseline characteristics of patients who did and did not undergo surgery were compared. RESULTS: Of 449 eligible POSH referrals within the study period, 33 (7.3%) did not proceed to surgery; cancellation rates within the POSH program were lower than institutional cancellation rates for adults over age 65 who did not participate in POSH. Patients who did not have surgery were significantly older, more likely to have functional limitations, and had higher rates of several comorbidities compared with those who proceeded to surgery (P < 0.05). Reasons for surgical cancellations included a similar number of patient- and provider-driven causes. CONCLUSIONS: Many reasons for surgical cancellation were related to potentially modifiable factors, such as changes in goals of care or concerns about rehabilitation, emphasizing the importance of shared decision-making in elective surgery for older adults. These results highlight the important role geriatric collaborative care can offer to older adults with complex needs.

Delaying Elective Surgery in Geriatric Patients: An Opportunity for Preoperative Optimization.

Deciding whether to pursue elective surgery is a complex process for older adults. Comprehensive geriatric assessment (CGA) can help refine estimates of benefits and risks, at times leading to a delay of surgery to optimize surgical readiness. We describe a cohort of geriatric patients who were evaluated in anticipation of elective abdominal surgery and whose procedures were delayed for any reason. Themes behind the reasons for delay are described, and a holistic framework to guide preoperative discussion is suggested.

An innovative educational clinical experience promoting geriatric exercise.

Formal educational training in physical activity promotion is relatively sparse throughout the medical education system. The authors describe an innovative clinical experience in physical activity directed at medical clinicians on a geriatrics rotation. The experience consists of a single 2 1/2 hour session, in which learners are partnered with geriatric patients engaged in a formal supervised exercise program. The learners are guided through an evidence-based exercise regimen tailored to functional status. This experience provides learners with an opportunity to interact with geriatric patients outside the hospital environment to counterbalance the typical geriatric rotation in which geriatric patients are often seen in clinics or hospitals. In this experience, learners are exposed to fit and engaged geriatric patients successfully living in the community despite chronic or disabling conditions. A survey of 105 learners highlighted positive responses to the experience, with 96% of survey respondents indicating that the experience increased their confidence in their ability to serve as advocates for physical activity for older adults, and 89.5% of responders to a follow-up survey indicating that the experience changed their perception of geriatric patients. Modifications to the experience, implemented at partnering facilities are described. The positive feedback from this experience warrants consideration for implementation in other settings.

Development and validation of machine learning models to identify high-risk surgical patients using automatically curated electronic health record data (Pythia): A retrospective, single-site study.

BACKGROUND: Pythia is an automated, clinically curated surgical data pipeline and repository housing all surgical patient electronic health record (EHR) data from a large, quaternary, multisite health institute for data science initiatives. In an effort to better identify high-risk surgical patients from complex data, a machine learning project trained on Pythia was built to predict postoperative complication risk. METHODS AND FINDINGS: A curated data repository of surgical outcomes was created using automated SQL and R code that extracted and processed patient clinical and surgical data across 37 million clinical encounters from the EHRs. A total of 194 clinical features including patient demographics (e.g., age, sex, race), smoking status, medications, comorbidities, procedure information, and proxies for surgical complexity were constructed and aggregated. A cohort of 66,370 patients that had undergone 99,755 invasive procedural encounters between January 1, 2014, and January 31, 2017, was studied further for the purpose of predicting postoperative complications. The average complication and 30-day postoperative mortality rates of this cohort were 16.0% and 0.51%, respectively. Least absolute shrinkage and selection operator (lasso) penalized logistic regression, random forest models, and extreme gradient boosted decision trees were trained on this surgical cohort with cross-validation on 14 specific postoperative outcome groupings. Resulting models had area under the receiver operator characteristic curve (AUC) values ranging between 0.747 and 0.924, calculated on an out-of-sample test set from the last 5 months of data. Lasso penalized regression was identified as a high-performing model, providing clinically interpretable actionable insights. Highest and lowest performing lasso models predicted postoperative shock and genitourinary outcomes with AUCs of 0.924 (95% CI: 0.901, 0.946) and 0.780 (95% CI: 0.752, 0.810), respectively. A calculator requiring input of 9 data fields was created to produce a risk assessment for the 14 groupings of postoperative outcomes. A high-risk threshold (15% risk of any complication) was determined to identify high-risk surgical patients. The model sensitivity was 76%, with a specificity of 76%. Compared to heuristics that identify high-risk patients developed by clinical experts and the ACS NSQIP calculator, this tool performed superiorly, providing an improved approach for clinicians to estimate postoperative risk for patients. Limitations of this study include the missingness of data that were removed for analysis. CONCLUSIONS: Extracting and curating a large, local institution's EHR data for machine learning purposes resulted in models with strong predictive performance. These models can be used in clinical settings as decision support tools for identification of high-risk patients as well as patient evaluation and care management. Further work is necessary to evaluate the impact of the Pythia risk calculator within the clinical workflow on postoperative outcomes and to optimize this data flow for future machine learning efforts.

A Perioperative Medicine Model for Population Health: An Integrated Approach for an Evolving Clinical Science.

Health care delivery in the United States continues to balance on the tight rope that connects its transition from volume to value. Value in economic terms can be defined as the amount something exceeds its commodity price and is determined by extraordinary reputation, quality, and/or service, whereas its destruction can be a consequence of poor management, unfavorable policy, decreased demand, and/or increased competition. Going forward, payment for health care delivery will increasingly be based on services that contribute to improvements in individual and/or population health value, and funds to pay for health care delivery will become increasingly vulnerable to competitive market forces. Therefore, a sustainable population health strategy needs to be comprehensive and thus include perioperative medicine as an essential component of the complete cycle of patient-centered care. We describe a multidisciplinary integrated program to support perioperative medicine services that are integral to a comprehensive population health strategy.

Surviving the Silver Tsunami: Training a Health Care Workforce to Care for North Carolina's Aging Population.

North Carolina's aging population will require a health care workforce prepared to meet patients' complex care needs. The keys to training this workforce include continuing to mobilize the state's educational infrastructure to provide interprofessional, community-based experiences and maximizing exposure to new models of care.

Development and implementation of a formalized geriatric surgery curriculum for general surgery residents.

Despite the growth of the elderly population, most surgical training programs lack formalized geriatric education. The authors' aim was to implement a formalized geriatric surgery curriculum at an academic medical center. Surgery residents were surveyed on attitudes toward the care of elderly patients and the importance of various geriatric topics to daily practice. A curriculum consisting of 16 didactic sessions was created with faculty experts moderating. After curriculum completion, residents were surveyed to assess curriculum impact. Residents expressed increased comfort in accessing community resources. A greater percentage of residents recognized the significance of delirium and acute renal failure in elderly patients. Implementing a geriatric surgery curriculum geared toward surgery residents is feasible and can increase resident comfort with multidisciplinary care and recognition of clinical conditions pertinent to elderly surgical patients. This initiative also provided valuable experience for geriatric surgery curriculum development.

Design and evaluation of a prelicensure interprofessional course on improving care transitions.

Effective management of care transitions for older adults require the coordinated expertise of an interprofessional team. Unfortunately, different health care professions are rarely educated together or trained in teamwork skills. To address this issue, a team of professionally diverse faculty from the Duke University Geriatric Education Center designed an interprofessional course focused on improving transitions of care for older adults. This innovative prelicensure course provided interactive teaching sessions designed to promote critical thinking and foster effective communication among health care professionals, caregivers, and patients. Students were assessed by in-class and online participation, performance on individual assignments, and team-based proposals to improve care transitions for older patients with congestive heart failure. Twenty students representing six professions completed the course; 18 completed all self-efficacy and course evaluation surveys. Students rated their self-efficacy in several domains before and after the course and reported gains in teamwork skills (p < .001), transitions of care (p < .001), quality improvement (p < .001) and cultural competence (p < .001). Learner feedback emphasized the importance of enthusiastic and well-prepared faculty, interactive learning experiences, and engagement in relevant work. This course offers a promising approach to shifting the paradigm of health professions education to empower graduates to promote quality improvement through team-based care.

Development, Implementation, and Assessment of an Online Modular Telehealth Curriculum for Health Professions Students.

Purpose: Several national health profession organizations endorse or have developed competencies for telehealth, yet there is no standardized curriculum for teaching telehealth to health professions students. Additionally, implementing telehealth curricula is challenging due to limited curricular space and differing needs of various health profession programs. We describe the development, implementation, and pilot assessment of an online, modular telehealth curriculum for health professions students. Methods: An online, modular telehealth curriculum for health professions students was developed in 2021-2022. Nine modules were created, focusing on the logistics of performing a telehealth visit and system-based virtual assessments. In academic year 2022-2023, course directors from the Duke doctor of medicine (MD), physician assistant (PA), and nurse practitioner (NP) programs utilized modules in their courses. For modules taken, students were surveyed and self-assessed their confidence, knowledge gained, and likelihood of utilizing the telehealth skills taught in the module(s). Results: During the 2022-2023 academic year, MD, NP, and PA students at Duke participated in one or more of the telehealth modules in an existing course. The median responses to self-assessed confidence questions for all health profession students to be in the "moderately" or "very confident" range. Similarly, students reported a median response of "moderate knowledge gained" for each module taken. NP students reported slightly lower levels of confidence and likelihood of utilizing telehealth skills than other professions. No other significant differences in the remainder of responses were observed between health professions. Conclusion: Exposure of health professions students to telehealth through utilization of online, interactive modules may result in increased telehealth skill confidence and knowledge, and furthermore, a belief that they will utilize these skills in future practice. Larger scale implementation of the telehealth curriculum and development of outcome measures which assess clinical application of skills conveyed will provide more information about the efficacy of the curriculum.

Participatory research to improve medication reconciliation for older adults in the community.

INTRODUCTION: Medication reconciliation, a technique that assists in aligning a care team's understanding of an individual's true medication regimen, is vital to optimize medication use and prevent medication errors. Historically, most medication reconciliation research has focused on institutional settings and transitional care, with comparatively little attention given to medication reconciliation in community settings. To optimize medication reconciliation for community-dwelling older adults, healthcare professionals and older adults must be engaged in co-designing processes that create sustainable approaches. METHODS: Academic researchers, older adults, and community- and health system-based healthcare professionals engaged in a participatory process to better understand medication reconciliation barriers and co-design solutions. The initiative consisted of two participatory research approaches: (1) Sparks Innovation Studios, which synthesized professional expertise and opinions, and (2) a Community Consultation Studio with older adults. Input from both groups informed a list of possible solutions and these were ranked based on evaluative criteria of feasibility, person-centeredness, equity, and sustainability. RESULTS: Sparks Innovation Studios identified a lack of ownership, fragmented healthcare systems, and time constraints as the leading barriers to medication reconciliation. The Community Consultation Studio revealed that older adults often feel dismissed in medical encounters and perceive poor communication with and among providers. The Community Consultation Studio and Sparks Innovation Studios resulted in four highly-ranked solutions to improve medication reconciliation: (1) support for older adults to improve health literacy and ownership; (2) ensuring medication indications are included on prescription labels; (3) trainings and incentives for front-line staff in clinic settings to become champions for medication reconciliation; and (4) electronic health record improvements that simplify active medication lists. CONCLUSION: Engaging community representatives with academic partners in the research process enhanced understanding of community priorities and provided a practical roadmap for innovations that have the potential to improve the well-being of community-dwelling older adults.

Geriatric Preoperative Optimization: A Review.

This review summarizes best practices for the perioperative care of older adults as recommended by the American Geriatrics Society, American Society of Anesthesiologists, and American College of Surgeons, with practical implementation strategies that can be readily implemented in busy preoperative or primary care clinics. In addition to traditional cardiopulmonary screening, older patients should undergo a comprehensive geriatric assessment. Rapid screening tools such as the Mini-Cog, Patient Health Questionnaire-2, and Frail Non-Disabled Survey and Clinical Frailty Scale, can be performed by multiple provider types and allow for quick, accurate assessments of cognition, functional status, and frailty screening. To assess polypharmacy, online resources can help providers identify and safely taper high-risk medications. Based on preoperative assessment findings, providers can recommend targeted prehabilitation, rehabilitation, medication management, care coordination, and/or delirium prevention interventions to improve postoperative outcomes for older surgical patients. Structured goals of care discussions utilizing the question-prompt list ensures that older patients have a realistic understanding of their surgery, risks, and recovery. This preoperative workup, combined with engaging with family members and interdisciplinary teams, can improve postoperative outcomes.

Planning for a Safe Discharge: More Than a Capacity Evaluation.

Discharge decision making for hospitalized older adults can be a complicated process involving functional assessments, capacity evaluation, and coordination of resources. Providers may feel pressured to recommend that an older adult with complex care needs be discharged to a skilled nursing facility rather than home, potentially contradicting the patient's wishes. This can lead to a professional and ethical dilemma for providers, who value patient autonomy and shared decision making. We describe a discharge decision-making framework focused on interprofessional evaluation and management, longitudinal follow-up, and education and support for patients and families. By gathering and synthesizing information, eliciting goals and preferences, and identifying community resources, the healthcare team can help maximize independence for vulnerable older adults. J Am Geriatr Soc 68:859-866, 2020.

'So you want to be a clinician-educator...': designing a clinician-educator curriculum for internal medicine residents.

BACKGROUND: Despite a growing demand for skilled teachers and administrators in graduate medical education, clinician-educator tracks for residents are rare and though some institutions offer 'resident-as-teacher' programs to assist residents in developing teaching skills, the need exists to expand training opportunities in this area. METHODS: The authors conducted a workshop at a national meeting to develop a description of essential components of a training pathway for internal medicine residents. Through open discussion and small group work, participants defined the various roles of clinician-educators and described goals, training opportunities, assessment and resource needs for such a program. RESULTS: Workshop participants posited that the clinician-educator has several roles to fulfill beyond that of clinician, including those of teacher, curriculum developer, administrator and scholar. A pathway for residents aspiring to become clinician educators must offer structured training in each of these four areas to empower residents to effectively practice clinical education. In addition, the creation of such a track requires securing time and resources to support resident learning experiences and formal faculty development programs to support institutional mentors and leaders. CONCLUSION: This article provides a framework by which leaders in medical education can begin to prepare current trainees interested in careers as clinician-educators.

Exploring patient-provider decision-making for use of anticoagulation for stroke prevention in atrial fibrillation: Results of the INFORM-AF study.

BACKGROUND: Atrial fibrillation is associated with stroke, yet approximately 50% of patients are not treated with guideline-directed oral anticoagulants (OACs). AIMS: Given that the etiology of this gap in care is not well understood, we explored decision-making by patients and physicians regarding OAC use for stroke prevention in atrial fibrillation. METHODS AND RESULTS: We conducted a descriptive qualitative study among providers ( N=28) and their patients with atrial fibrillation for whom OACs were indicated ( N=25). We used purposive sampling across three outpatient settings in which atrial fibrillation patients are commonly managed: primary care ( n=14), geriatrics ( n=10), and cardiology ( n=4). Eligible patients were stratified by those prescribed OAC ( n=13) and not prescribed OAC ( n=12). Semi-structured, in-depth interviews assessed decision-making regarding risk and OAC use. Classical content analysis was used to code narratives and identify themes. Results among patients consisted of the overarching theme of trust in provider recommendations. Sub-themes included: awareness of increased risk of stroke with atrial fibrillation; willingness to accept medications recommended by their physician; and low demand for explanatory decision aids. Among physicians, the overarching theme was decisional conflict regarding the balance between stroke and bleeding risk, and the optimal medication to prescribe. Subthemes included: absence of decision aids for communication; and misperceptions around the assessment and management of stroke risk with atrial fibrillation. CONCLUSIONS: Patient involvement in decision-making around OAC use did not occur in this study of patients with atrial fibrillation. Improved access to decision aids may increase patient engagement in the decision-making process of OAC use for stroke prevention.

Preoperative Screening.

Older adults undergoing elective surgical procedures suffer higher rates of morbidity and mortality than younger patients. A geriatric-focused preoperative evaluation can identify risk factors for complications and opportunities for health optimization and care coordination. Key components of a geriatric preoperative evaluation include (1) assessments of function, mobility, cognition, and mental health; (2) reviews of medical conditions and medications; and (3) discussion of risks, preferences, and goals of care. A geriatric-focused, team-based approach can improve surgical outcomes and patient experience.