Hospital readmission after hip fracture.

INTRODUCTION: Readmission to the hospital following a hip fracture is common, often involves an adverse event, and strains an already overburdened health care system. OBJECTIVES: To assess the rate of 30-day readmission to the hospital after discharge for care of hip fracture. A secondary objective was measurement of the 30-day mortality rate for those patients readmitted versus those patients not readmitted to the hospital after discharge. MATERIALS AND METHODS: Study design was a retrospective review of registry data comparing readmitted patients to those not readmitted after hip fracture. Setting was a university affiliated level 3 trauma center. PARTICIPANTS: 1,081 patients aged 65 and older. MEASUREMENTS: rate of readmission, rate of mortality, predictors of readmission. RESULTS: 129 patients (11.9 %) were readmitted to the hospital within 30 days of their initial discharge date. The primary causes of readmission were surgical in nature for 24/129 (18.6 %) patients and 105/129 (81.4 %) were readmitted for medical or other reasons. Twenty-four (18.6 %) patients who were readmitted died during readmission. The one-year mortality rate for patients readmitted within 30 days was 56.2 vs. a 21.8 % 1-year mortality rate for those patients not readmitted (p < 0.0001). Independent predictors of readmission were age >85 (OR = 1.52; p = 0.03), time to surgery >24 h (OR = 1.50; p = 0.05), Charlson score ≥4 (OR = 1.70; p = 0.04), delirium (OR = 1.65; p = 0.01), dementia (OR = 1.61; p = 0.01), history of arrhythmia with pacemaker placement (OR = 1.75; p = 0.02), and presence of a pre-op arrhythmia (OR = 1.62; p = 0.02). CONCLUSION: Readmission after hip fracture is harmful and undesirable-18.6 % of readmitted patients died during their readmission and the average length of stay was 8.7 days. Approximately one of every six readmissions was identified as potentially preventable with interventions.

Piloting a brief assessment to capture consumption of whole plant food and water: version 1.0 of the American College of Lifestyle Medicine Diet Screener (ACLM Diet Screener).

Background: Despite the availability of various dietary assessment tools, there is a need for a tool aligned with the needs of lifestyle medicine (LM) physicians. Such a tool would be brief, aimed at use in a clinical setting, and focused on a "food as medicine" approach consistent with recommendations for a diet based predominately on whole plant foods. The objective of this study is to describe the development and initial pilot testing of a brief, dietary screener to assess the proportion of whole, unrefined plant foods and water relative to total food and beverage intake. Methods: A multidisciplinary study team led the screener development, providing input on the design and food/beverage items included, and existing published dietary assessment tools were reviewed for relevance. Feedback was solicited from LM practitioners in the form of a cross-sectional survey that captured information on medical practice, barriers, and needs in assessing patients' diets, in addition to an opportunity to complete the screener and provide feedback on its utility. The study team assessed feedback and revised the screener accordingly, which included seeking and incorporating feedback on additional food items to be included from subject matter experts in specific cultural and ethnic groups in the United States. The final screener was submitted for professional design, and scoring was developed. Results: Of 539 total participants, the majority reported assessing diet either informally (62%) or formally (26%) during patient encounters, and 73% reported discussing diet with all or most of their patients. Participants also reported facing barriers (80%) to assessing diet. Eighty-eight percent believed the screener was quick enough to use in a clinical setting, and 68% reported they would use it. Conclusion: The ACLM Diet Screener was developed through iterative review and pilot testing. The screener is a brief, 27-item diet assessment tool that can be successfully used in clinical settings to track patient dietary intakes, guide clinical conversations, and support nutrition prescriptions. Pilot testing of the screener found strong alignment with clinician needs for assessing a patient's intake of whole plant food and water relative to the overall diet. Future research will involve pilot testing the screener in clinical interventions and conducting a validation study to establish construct validity.

"Geriatricizing" hospitalists: identifying educational opportunities.

The objective of this study was to identify differences between geriatricians and hospitalists in caring for hospitalized older adults, so as to inform faculty development programs that have the goal of improving older patient care. Eleven hospitalists and 13 geriatricians were surveyed regarding knowledge, confidence, and practice patterns in caring for hospitalized older adults, targeting areas previously defined as central to taking care of older hospitalized patients. Overall, geriatricians had more confidence and more knowledge in caring for older hospitalized adults. The areas in which hospitalists expressed the least confidence were in caring for patients with dementia, self-care issues, and care planning. Geriatricians reported more routine medication reviews, functional and cognitive assessments, and fall evaluations. Geriatricians and hospitalists differ in their approach to older adults. Where these differences reflect lack of knowledge or experience, they set the stage for developing curricula to help narrow these gaps.

Whole-food plant-based Jumpstart for a Deaf and Hard of Hearing cohort.

Deaf and Hard of Hearing (DHH) patients are at high risk of developing chronic illness, and when they do, are at higher risk of poor outcomes than in a hearing community. Rochester Lifestyle Medicine Institute adapted its online, Zoom-based, medically-facilitated 15 Day Whole-Food Plant-Based (WFPB) Jumpstart program, to give DHH participants knowledge, skills, and support to make dietary changes to improve their health. Adaptations included having a medical provider present who is fluent in American Sign Language (ASL), is board-certified in Lifestyle Medicine, and has a Master of Science in Deaf Education; spotlighting participants when asking a question during the Q&A session; using ASL interpreters; utilizing closed captioning/automatic transcription during all Zoom meetings; and employing a Success Specialist to provide outreach via text and email throughout the program. Participants had significant positive changes in their eating pattern. They reported improvements in biometric measures as well as in how they were feeling. They all reported that they planned to continue to eat a more WFPB diet than they did prior to Jumpstart. All either agreed or strongly agreed that they learned important information, were confident that they knew the best eating pattern for health, and gained the skills they needed to make changes. Although this was a small pilot program, it suggests that this model can be used to provide education and support for behavior change that will lead to improved health in a DHH community.

A whole-food, plant-based program in an African American faith-based population.

Background: The African American (AA) population is disproportionately impacted by chronic disease as well as many of the leading causes of preventable death, including hypertension, obesity, heart disease, stroke, and type 2 diabetes. In the AA community of Kane County, Illinois, the incidence of chronic disease is particularly high. A standardized Zoom-based group program that gives participants the knowledge, skills, and support to adopt a whole-food plant-based diet has been shown to rapidly improve health. The results of a cohort analysis were analyzed to assess the effectiveness of this program within an AA community characterized by a high burden of chronic illnesses. Methods: Participants were recruited from a network of 12 AA churches in Illinois to participate in Rochester Lifestyle Medicine Institute's "15-Day Whole-Food Plant-Based (WFPB) Jumpstart" program. The medically-facilitated 15-Day Jumpstart program provided WFPB nutrition education, coaching, and cooking demonstrations during seven 1 and 2-h Zoom sessions. Participants underwent pre- and post- metabolic screenings to assess for changes in their weight, vital signs, blood sugar, and cholesterol measurements. Changes in diet, biometrics, and patient-centered outcomes from baseline to the end of the program were assessed via paired t-tests for the normally distributed measures, and a Wilcoxon signed rank test for measures that were not normally distributed. Results: Twenty-one AA adults participated. Ten of 16 who provided results had hypertension, 5 had diabetes, 5 had pre-diabetes, and 5 had hyperlipidemia. Participants ate more vegetables (median 2 servings at baseline vs. 3 during the program), greens (1 vs. 3), fruit (2 vs. 3), whole grains (1 vs. 2), and legumes (1 vs. 2). They decreased their consumption of meat, eggs and dairy, added fat, processed foods, and high-fat plant foods (p < 0.05 for each comparison). Participants reported significantly better energy (median 5 at baseline vs. 9 during the program, on a 10-point scale), sleep (7 vs. 8.5), and mood (8 vs. 9). Average weight loss was 5.8 pounds (199.9 to 194.1, p < 0.001), systolic blood pressure dropped from 129.7 to 119.9 (p = 0.02), and total cholesterol dropped from 185.1 to 147.9 (p < 0.001). All participants who provided data reported an intent to continue eating at least a partially WFPB diet following the program. Conclusion: The 15-Day WFPB Jumpstart program led to significant changes in diet, resulting in improvement in several chronic disease measures in this AA community. This rapid improvement can reinforce behavior change. Further large-scale implementation is needed to confirm these preliminary results and to understand whether behaviors and outcomes are sustained.

Lifestyle Medicine in the Midst of a Pandemic.

Patients with chronic conditions are at higher risk of complications and mortality if they get COVID-19. Approximately half of American adults have at least 1 condition that increases their risk of complications if they become infected. The medical and public health communities need to send a clear message about the impact of lifestyle on health, particularly in the time of this pandemic. We need to communicate with patients and the public, to let them know how rapidly major lifestyle changes can improve health. This communication is urgent; the timeline for self-care and lifestyle medicine interventions has been telescoped, so that chronic diseases are now acute risk factors.

Medicare's annual wellness visit: 10 years of opportunities gained and lost.

Medicare annual wellness visits (AWV) were initiated 10 years ago. Though AWVs emphasize on disease prevention and health promotion for older adults was a huge step forward, the current "one size fits all" approach does not adequately meet the wellness needs of a diverse population of older adults. Current AWVs do not sufficiently take into consideration the medical, psychological, functional, racial, cultural and socio-economic diversity of older adults. Updated AWVs should be tailored to meet the needs and priorities of older adults receiving them. Several geriatrics approaches to care, including geriatrics Glidepaths and the 4Ms of an Age-Friendly Health System, could help develop and guide a more patient-specific geriatrics focused approach to AWVs. Medicare's IPPE is an ideal time to advise new Medicare beneficiaries regarding what they should and should not do to maximize their ability to be healthy and functionally independent into their 80s, 90s, and 100s.

Jumpstarting Health With a 15-Day Whole-Food Plant-Based Program.

The 15-day Jumpstart was developed as an evidence-based, affordable, standardized, replicable, and scalable program, designed to demonstrate quickly to patients that changing what they eat can improve their health. The program was designed using the principles of the self-determination theory of motivation and personality. Patients were instructed to eat an Esselstyn-compliant, whole-food plant-based diet consisting of vegetables, fruits, whole grains, and legumes. Of the 389 participants in the program from September 2018 to February 2020, average weight loss was 5.8 pounds (7.3 for those whose body mass index was >30), average systolic blood pressure drop was 6.8 points (16.8 points for those with systolic blood pressure >140), average drop in cholesterol was 26 points (44 points for those with a cholesterol >200), average drop in low-density lipoprotein was 19 points (33 points for those with a low-density lipoprotein >100), and average drop in fasting blood sugar was 5.1 points (28.4 points for those starting in the diabetic range); P value was <.005 for fasting blood sugar and <.001 for all other comparisons. A 15-day program that helps patients adopt an Esselstyn-style whole-food plant-based diet, through education, individualized medical feedback, social support, and facilitated small group work, rapidly improves health.

Promoting Healthy Aging During COVID-19.

Older adults have been markedly impacted by the coronavirus disease 19 (COVID-19) pandemic. The American Geriatrics Society previously published a White Paper on Healthy Aging in 2018 that focused on a number of domains that are core to healthy aging in older adults: health promotion, injury prevention, and managing chronic conditions; cognitive health; physical health; mental health; and social health. The potentially devastating consequences of COVID-19 on health promotion are recognized. The purpose of this article is multifold. First, members of the Healthy Aging Special Interest Group will present the significant difficulties and obstacles faced by older adults during this unprecedented time. Second, we provide guidance to practicing geriatrics healthcare professionals overseeing the care of older adults. We provide a framework for clinical evaluation and screening related to the five aforementioned domains that uniquely impact older adults. Last, we provide strategies that could enhance healthy aging in the era of COVID-19.

Lifestyle Medicine Reimbursement: A Proposal for Policy Priorities Informed by a Cross-Sectional Survey of Lifestyle Medicine Practitioners.

Lifestyle medicine (LM) is a rapidly emerging clinical discipline that focuses on intensive therapeutic lifestyle changes to treat chronic disease, often producing dramatic health benefits. In spite of these well-documented benefits of LM approaches to provide evidence-based care that follows current clinical guidelines, LM practitioners have found reimbursement challenging. The objectives of this paper are to present the results of a cross-sectional survey of LM practitioners regarding lifestyle medicine reimbursement and to propose policy priorities related to the ability of practitioners to implement and achieve reimbursement for these necessary services. Results from a closed, online survey in 2019 were analyzed, with a total of n = 857 included in this analysis. Results were descriptively analyzed. This manuscript articulates policy proposals informed by the survey results. The study sample was 58% female, with median age of 51. A minority of the sample (17%) reported that all their practice was LM, while 56% reported that some of their practice was LM. A total of 55% of practitioners reported not being able to receive reimbursement for LM practice. Of those survey respondents who provided an answer to the question of what would make the practice of LM easier (n = 471), the following suggestions were offered: reimbursement overall (18%), reimbursement for more time spent with patients (17%), more support from leadership (16%), policy measures to incentivize health (13%), education in LM for practitioners (11%), LM-specific billing codes and billing knowledge along with better electronic medical record (EMR) capabilities and streamlined reporting/paperwork (11%), and reimbursement for the extended care team (10%). Proposed policy changes focus on three areas of focus: (1) support for the care process using a LM approach, (2) reimbursement emphasizing outcomes of health, patient experience, and delivering person-centered care, and (3) incentivizing treatment that produces disease remission/reversal. Rectifying reimbursement barriers to lifestyle medicine practice will require a sustained effort from health systems and policy makers. The urgency of this transition towards lifestyle medicine interventions to effectively address the epidemic of chronic diseases in a way that can significantly improve outcomes is being hindered by current reimbursement policies and models.

Lifestyle Medicine and Economics: A Proposal for Research Priorities Informed by a Case Series of Disease Reversal.

Chronic disease places an enormous economic burden on both individuals and the healthcare system, and existing fee-for-service models of healthcare prioritize symptom management, medications, and procedures over treating the root causes of disease through changing health behaviors. Value-based care is gaining traction, and there is a need for value-based care models that achieve the quadruple aim of (1) improved population health, (2) enhanced patient experience, (3) reduced healthcare costs, and (4) improved work life and decreased burnout of healthcare providers. Lifestyle medicine (LM) has the potential to achieve these four aims, including promoting health and wellness and reducing healthcare costs; however, the economic outcomes of LM approaches need to be better quantified in research. This paper demonstrates proof of concept by detailing four cases that utilized an intensive, therapeutic lifestyle intervention change (ITLC) to dramatically reverse disease and reduce healthcare costs. In addition, priorities for lifestyle medicine economic research related to the components of quadruple aim are proposed, including conducting rigorously designed research studies to adequately measure the effects of ITLC interventions, modeling the potential economic cost savings enabled by health improvements following lifestyle interventions as compared to usual disease progression and management, and examining the effects of lifestyle medicine implementation upon different payment models.

Lifestyle (Medicine) and Healthy Aging.

Healthy aging is a process that occurs over the life cycle. Health habits established early and practiced throughout life impact longevity, the ability to reach old age, and the health with which one experiences older adulthood. The new field of lifestyle medicine addresses root causes of disease by targeting nutrition, physical activity, well-being, stress management, substance use, connectedness, and sleep. As a result, lifestyle medicine can optimize the trajectory of aging, and promote targets that have been recognized in geriatric medicine as essential to well-being and quality of life, resulting in a compression of morbidity.

Healthy Aging: American Geriatrics Society White Paper Executive Summary.

In July 2015, the Journal of the American Geriatrics Society published a manuscript titled, "Failing to Focus on Healthy Aging: A Frailty of Our Discipline?" In response, the American Geriatrics Society (AGS) Clinical Practice and Models of Care Committee and Public Education Committee developed a white paper calling on the AGS and its members to play a more active role in promoting healthy aging. The executive summary presented here summarizes the recommendations from that white paper. The full version is published online at GeriatricsCareOnline.org. Life expectancy has increased dramatically over the last century. Longer life provides opportunity for personal fulfillment and contributions to community but is often associated with illness, discomfort, disability, and dependency at the end of life. Geriatrics has focused on optimizing function and quality of life as we age and reducing morbidity and frailty, but there is evidence of earlier onset of chronic disease that is likely to affect the health of future generations of older adults. The AGS is committed to promoting the health, independence, and engagement of all older adults as they age. Geriatrics as an interprofessional specialty is well positioned to promote healthy aging. We draw from decades of accumulated knowledge, skills, and experience in areas that are central to geriatric medicine, including expertise in complexity and the biopsychosocial model; attention to function and quality of life; the ability to provide culturally competent, person-centered care; the ability to assess people's preferences and values; and understanding the importance of systems in optimizing outcomes. J Am Geriatr Soc 67:17-20, 2019.

Hazards of hospitalization: residence prior to admission predicts outcomes.

PURPOSE: Previous studies investigating adverse outcomes of hospitalized elders have focused on community-dwelling patients. Given the rapid growth of populations living in other settings, such as assisted living facilities, it is important to understand whether these patients are at higher risk of experiencing specific adverse outcomes during hospitalization, so that interventions can be developed to reduce risk. METHODS: This is a prospective, observational study of 212 sequential patients admitted during a 1-month period in 2006 to a 38-bed Acute Care for Elders unit in Rochester, New York and followed until discharge. We categorized the patients by residence prior to admission (i.e., community, assisted living, and nursing home). Our outcome categories were: worsening function, delirium, depression, falls, pressure sores, and nursing home admission. RESULTS: After adjusting for multiple characteristics, we found that patients admitted from assisted living facilities were at substantially higher risk than those admitted from the community for functional decline and falls. Patients from nursing homes had a trend toward increased risk for these outcomes, but the trend did not reach statistical significance. More than three fourths of assisted living facility residents were discharged to a nursing home after hospitalization, with a relative risk of 9.41 (p <.001) versus community-dwellers for this outcome. IMPLICATIONS: People who are admitted to the hospital from assisted living facilities are at high risk for falls and functional decline during hospitalization. Assisted living residents are at a particularly high risk of nursing home admission following hospitalization. Targeted preventive programs should be developed with a goal of reducing risk in this vulnerable population.

Quality indicators for in-hospital geriatric co-management programmes: a systematic literature review and international Delphi study.

OBJECTIVE: To find consensus on appropriate and feasible structure, process and outcome indicators for the evaluation of in-hospital geriatric co-management programmes. DESIGN: An international two-round Delphi study based on a systematic literature review (searching databases, reference lists, prospective citations and trial registers). SETTING: Western Europe and the USA. PARTICIPANTS: Thirty-three people with at least 2 years of clinical experience in geriatric co-management were recruited. Twenty-eight experts (16 from the USA and 12 from Europe) participated in both Delphi rounds (85% response rate). MEASURES: Participants rated the indicators on a nine-point scale for their (1) appropriateness and (2) feasibility to use the indicator for the evaluation of geriatric co-management programmes. Indicators were considered appropriate and feasible based on a median score of seven or higher. Consensus was based on the level of agreement using the RAND/UCLA Appropriateness Method. RESULTS: In the first round containing 37 indicators, there was consensus on 14 indicators. In the second round containing 44 indicators, there was consensus on 31 indicators (structure=8, process=7, outcome=16). Experts indicated that co-management should start within 24 hours of hospital admission using defined criteria for selecting appropriate patients. Programmes should focus on the prevention and management of geriatric syndromes and complications. Key areas for comprehensive geriatric assessment included cognition/delirium, functionality/mobility, falls, pain, medication and pressure ulcers. Key outcomes for evaluating the programme included length of stay, time to surgery and the incidence of complications. CONCLUSION: The indicators can be used to assess the performance of geriatric co-management programmes and identify areas for improvement. Furthermore, the indicators can be used to monitor the implementation and effect of these programmes.

Informal caregivers and the risk of nursing home admission among individuals enrolled in the program of all-inclusive care for the elderly.

PURPOSE: We sought to determine whether participants in the Program of All-Inclusive Care for the Elderly (PACE) with an informal caregiver have a higher or lower risk of nursing home admission than those without caregivers. DESIGN AND METHODS: We performed a secondary data analysis of 3,189 participants aged 55 years or older who were enrolled in 11 PACE programs during the period from June 1, 1990 through June 30, 1998. Cox proportional hazard models determined whether having any caregiver, as well as specific caregiver characteristics, such as either living separately from the enrollee, being over the age of 75 years, providing personal care, not reducing or quitting work to provide care, or not being a spouse, predicted time to nursing home admission. RESULTS: Fewer than half of the participants (49.4%) lived with a caregiver, and 12.4% had no caregiver. Individuals who lived with their caregiver were frailer than either those who lived separately or those without a caregiver. We measured frailty in terms of functional and cognitive status, incontinence, and multiple behavioral disturbances. The presence of a caregiver did not change the risk for institutionalization. None of the caregiver characteristics were associated with a higher risk of nursing home admission. IMPLICATIONS: Unlike individuals in the general population, participants in PACE who lack an informal caregiver are not at higher risk of institutionalization. Further research is required to ascertain whether PACE's comprehensive formal services compensate for the lack of informal caregiving in limiting the risk for institutionalization.

Characteristics predicting nursing home admission in the program of all-inclusive care for elderly people.

PURPOSE: This study determined overall risk and predictors of long-term nursing home admission within the Program of All-Inclusive Care for the Elderly (PACE). DESIGN AND METHODS: DataPACE records for 4,646 participants aged 55 years or older who were enrolled in 12 Medicare- and Medicaid-capitated PACE programs during the period from June 1, 1990, to June 30, 1998, were obtained. Participants were enrolled for at least 30 days and had baseline evaluations within 30 days of enrollment. Cox proportional hazard models predicting an outcome of nursing home admission of 30 days or longer were estimated. RESULTS: The cumulative risk of admission to nursing homes for 30 days or longer was 14.9% within 3 years. Individuals enrolled from a nursing home were at very high risk for future admission, with a relative risk of 5.20 when compared with those living alone. Among individuals enrolled in PACE from the community, age, instrumental activity of daily living dependence, and bowel incontinence were predictive of subsequent nursing home admission. Asians and Blacks had a lower risk of institutionalization than Whites. However, other characteristics were not independently predictive of institutionalization, namely poor cognitive status, number of chronic conditions, activity of daily living deficits, urinary incontinence, several behavioral disturbances, and duration of program operation. Before adjusting for other variables, there was substantial site variability in risk of nursing home admission; this decreased considerably after other characteristics were adjusted for. IMPLICATIONS: Despite the fact that 100% of the PACE participants were nursing home certifiable, the risk of being admitted to a nursing home long term following enrollment from the community is low. The presence of some reversible risk factors may have implications for early intervention to reduce risk further, although the effect of these interventions is likely to be modest. Individuals who received long-term care in a nursing home prior to enrollment in PACE remain at high risk of readmission, despite the availability of comprehensive services.