Home Telemonitoring of Patients With Type 2 Diabetes: A Meta-Analysis and Systematic Review.

Telehealth has emerged as an evolving care management strategy that is playing an increasingly vital role, particularly with the onset of the coronavirus disease 2019 pandemic. A meta-analysis of 20 randomized controlled trials was conducted to test the effectiveness of home telemonitoring (HTM) in patients with type 2 diabetes in reducing A1C, blood pressure, and BMI over a median 180-day study duration. HTM was associated with a significant reduction in A1C by 0.42% (P = 0.0084). Although we found statistically significant changes in both systolic and diastolic blood pressure (-0.10 mmHg [P = 0.0041] and -0.07 mmHg [P = 0.044], respectively), we regard this as clinically nonsignificant in the context of HTM. Comparisons across different methods of transmitting vital signs suggest that patients logging into systems with moderate interaction with the technology platform had significantly higher reductions in A1C than those using fully automatic transmission methods or fully manual uploading methods. A1C did not vary significantly by study duration (from 84 days to 5 years). HTM has the potential to provide patients and their providers with timely, up-to-date information while simultaneously improving A1C.

Measuring Functional Status in Hospitalized Older Adults Through Electronic Health Record Documentation.

OBJECTIVES: Hospitalization-associated disability affects up to 60% of older adults; however, standardized measures of function are not routinely used and documented. We sought to determine whether nursing documentation in electronic medical records can be used to determine mobility status and associated clinical outcomes. METHODS: A retrospective study of 2383 medical patients aged 75 years and older was conducted at a large academic tertiary hospital in New York. Mobility (low, intermediate, and high) was the primary variable of interest. Short-term clinical outcomes, including length of stay (LOS), discharge disposition, and readmissions, were the primary outcome variables. RESULTS: Average age and Charlson Comorbidity Index were 84.7 (range 74-107) and 6.46, respectively; 84.5% of patients were documented to have been ambulatory before admission. More than half (52.8%) of the subjects with in-hospital mortality were in the low mobility group (27.2 vs 0.27 vs 0, P < 0.0001). Low mobility was associated with increased LOS (7.42 vs 5.69 vs 4.14, P < 0.0001), discharge to a skilled nursing facility (39.36 vs 14.67 vs 1.91, P < 0.0001), and 30-day readmission (24.40 vs 16.67 vs 10.93, P < 0.0001). After controlling for demographics, ambulatory status before admission, and Charlson Comorbidity Index, low mobility was statistically significantly associated with increased LOS, discharge to a skilled nursing facility, and 30-day readmissions. CONCLUSIONS: The use of documented nursing observation may provide a practical way to systematically identify patients at risk for poor outcomes associated with low mobility to ultimately improve outcomes of hospitalized older adults.

Reasons for Chemotherapy Refusal or Acceptance in Older Adults With Cancer.

OBJECTIVES: The majority of Americans diagnosed as having cancer are older than 65 years. They are, however, less likely than younger patients to receive chemotherapy. Our study aimed to better understand the specific reasons for acceptance or refusal of chemotherapy in older adults with cancer. METHODS: An anonymous cross-sectional survey was distributed during a 6-month study period in a cancer center and an outpatient geriatric medicine faculty practice to patients at least 50 years old with cancer or to their family members. Data collected included reasons for refusal or acceptance, stage/type of cancer, and demographics. The association between chemotherapy refusal or initiation and these factors was assessed using the Fisher exact test. RESULTS: Among the 37 respondents meeting the inclusion criteria, 78.4% were patients and 21.6% were family members. The following factors were significantly associated with chemotherapy decision: perceived chemotherapy benefit (P < 0.001), trust in the doctor's recommendation (P = 0.013), social support (P = 0.018), marital status (P < 0.001), sex (P = 0.037), race/ethnicity (P = 0.021), and whether respondents had a family member or friend who had previously received chemotherapy (P = 0.040). In contrast, none of the clinical variables, such as stage of cancer, previous receipt of chemotherapy, or interest in complementary/alternative medicine showed significant association with a patient's decision to accept or refuse chemotherapy treatment. CONCLUSIONS: Chemotherapy decisions made by older adults appear to be associated with demographic and social factors rather than with medical information. Recognizing the influence of these factors for older patients with cancer may help hematologists and oncologists to proactively address specific barriers and explore concerns regarding chemotherapy in older patients whose quality of life and longevity may be affected by treatment.

Association between Weight Change, Health Outcomes, and Mortality in Older Residents in Long-Term Care.

OBJECTIVES: Despite the numerous health risks associated with being overweight, the effect of weight loss on health and longevity remains controversial, particularly in older adults. We explored the association among weight changes, health outcomes, and mortality in older residents of a skilled nursing facility. METHODS: A 6-year retrospective chart review of residents of a long-term care facility was conducted, collecting monthly weights in addition to the clinical and demographic data of all residents for at least 1 year. Weight changes of 5% from baseline month 1 through month 12 were classified as stable, loss, or gain. Demographics, body mass index (BMI), comorbidities, number of hospitalizations, and mortality were analyzed. The association between weight change (and other demographic and clinical variables) and mortality outcomes, as well as number of hospitalizations, was assessed using the χ2 test, the Fisher exact test, Poisson regression, or negative binomial regression, as appropriate. RESULTS: A total of 116 residents fit inclusion criteria; the median age was 84 years, with 71.6% being women and 88.7% white. The median length of stay was 877.5 days. Median body weight at baseline was 137.3 lb with a BMI of 23.5. More than one-third (36.2%) of residents had stable weight, 37.9% gained weight, and 25.9% lost weight during their stay. Neither weight change category nor baseline BMI was significantly associated with mortality (P = 0.056 and P = 0.518, respectively). Multivariable models showed that receiving supplementation (P = 0.04) and having hypertension (P = 0.04) were significant predictors of mortality after adjusting for the other factors. Losing >5% body weight (compared with maintaining stable weight; P = 0.0097), being a man (P = 0.0104), receiving a supplement (P = 0.0171), and being fed by tube (P = 0.0004) were associated with an increased number of hospitalizations after covariate adjustment. CONCLUSIONS: Weight fluctuation and baseline BMI do not appear to be associated with increased risk of death in residents in a skilled nursing facility. Weight loss was associated with an increased number of hospitalizations, however.

Perceptions of Older Adults, Hematologists, and Medical Oncologists in Cancer Care.

OBJECTIVES: The purpose of this study was to assess and compare the perceptions of hematologists, medical oncologists, cancer patients aged 65 years and older, and family members/caregivers regarding the value of a geriatric assessment (GA) in the management of older adults with cancer. METHODS: Participants included adults with cancer aged 65 years and older (n = 66), patient family members/caregivers (n = 32), and physicians (n = 42). A patient survey, a caregiver/family survey, and an online physician survey targeted to hematologists and medical oncologists were distributed at a large cancer center in a major academic health system in the New York metropolitan area. The χ(2) test or the Fisher exact test was used to compare the cohorts for responses to geriatric domains in a GA. RESULTS: Comparisons for each of the 17 GA domains between patient and family member and caregiver responses showed concordance, except for the perception of comorbidities; 16.7% of patients indicated that comorbidities were an issue, compared with 29.0% of family/caregivers (P = 0.047). Physicians indicated that a GA would be most helpful in addressing cognitive impairment (91.4%), falls (91.4%), and functional status (88.6%). CONCLUSIONS: A GA would be useful for physicians and older adults with cancer. Hematologists and medical oncologists recognize the utility of a GA and are receptive to a multidisciplinary geriatrics-oncology collaboration.

Antithrombotic Therapy Practices in Older Adults Residing in the Long-Term Care Setting.

OBJECTIVES: To explore physician practice patterns with regard to antithrombotic therapy, including antiplatelets and anticoagulants, in long-term care residents and compare resulting embolic complications. METHODS: Conducted between August 2012 and March 2013, this study was a retrospective chart review of 400 residents of a long-term care facility. Electronic charts from October 2005 through January 2013 were selected using systematic random sampling. RESULTS: Approximately one-third of residents (29.6%) received anticoagulants, 27.3% received antiplatelets, 15.8% received both, and 27.3% did not receive any antithrombotic therapy. The most commonly prescribed antithrombotic drugs were aspirin (37.5%) and warfarin (22.1%). The type of antithrombotic therapy was significantly associated with medical history, including deep vein thrombosis (P = 0.03), the presence of atrial fibrillation (P = 0.001) and other nonsurgical medical conditions (P = 0.0001). Weight (P = 0.009) and body mass index (P = 0.007) also were significantly associated with type of antithrombotic therapy, indicating that heavier residents and those with a higher body mass index were more likely to receive both anticoagulants and antiplatelets. There was no difference in the number of embolic complications among groups. CONCLUSIONS: Physicians are more disposed to initiate and maintain residents on aspirin while being more cautious when prescribing anticoagulants such as warfarin, dabigatran, heparin, and enoxaparin. In some residents, anticoagulants were not used at all, even when residents had particular risk factors, demonstrating that at times physicians may err on the side of overcautiousness. Antithrombotic therapy should be individualized for each resident based on bleeding risk, comorbidities, and benefits of a particular therapy for our most vulnerable populations.

The relationship between the timing of a palliative care consult and utilization outcomes for ventilator-assisted intensive care unit patients.

OBJECTIVE: Given the great number of chronic care patients facing the end of life and the challenges of critical care delivery, there has been emerging evidence supporting the benefit of palliative care in the intensive care unit (ICU). We studied the relationship between the timing of a palliative care consult (PCC) and two utilization outcomes - length of stay (LOS) and pharmacy costs - in ventilator-assisted ICU patients. METHOD: A retrospective chart review was conducted (N = 90). Summed pharmacy costs were compared using a paired t test before and after PCC. Spearman correlations were performed between days to PCC and ICU LOS, ventilator days, and days to death following ventilator discontinuation. RESULTS: Number of days from admission to PCC was correlated with total days on ventilator (ρ = 0.685, p < 0.0001) and total ICU LOS (ρ = 0.654, p < 0.0001). Number of days to PCC was correlated with pre-PCC total medication costs (ρ = 0.539, p < 0.0001). Median medication costs were significantly reduced after the PCC (p < 0.0001), from $230.96 to 30.62. Median medication costs decreased for all categories except for analgesics, antiemetics, and opioids. The number of patients receiving opioid infusion increased (37 vs. 90%) after PCC (p < 0.0001). SIGNIFICANCE OF RESULTS: Earlier timing for PCC in the ICU is associated with a lower LOS through quicker mechanical ventilation (MV) withdrawal, presenting a unique opportunity to both decrease costs and improve patient care.

Does a palliative care consult decrease the cost of caring for hospitalized patients with dementia?

OBJECTIVE: Advanced dementia (AD) is a terminal disease. Palliative care is increasingly becoming of critical importance for patients afflicted with AD. The primary objective of this study was to compare pharmacy cost before and after a palliative care consultation (PCC) in patients with end-stage dementia. A secondary objective was to investigate the cost of particular types of medication before and after a PCC. METHOD: This was a retrospective study of 60 hospitalized patients with end-stage dementia at a large academic tertiary care hospital from January 1, 2010 to October 1, 2011, in order to investigate pharmacy costs before and after a PCC. In addition to demographics, we carried out a comparison of the average daily pharmacy cost and comparison of the proportion of subjects taking each medication type (cardiac, analgesics, antibiotics, antipsychotics and antiemetics) before and after a PCC. RESULTS: There was a significant decrease in overall average daily pharmacy cost from before to after a PCC ($31.16 ± 24.71 vs. $20.83 ± 19.56; p < 0.003). There was also a significant difference in the proportion of subjects taking analgesics before and after PCC (55 vs. 73.3%; p < 0.009), with a significant average daily analgesic cost rise from pre- to post-PCC: $1.36 ± 5.07 (median = $0.05) versus. $2.35 ± 5.35 (median = $0.71), respectively, p < 0.011; average daily antiemetics cost showed a moderate increase from pre- to post-PCC: $0.08 ± 0.37 (median = $0) versus $0.23 ± 0.75 (median = $0), respectively, p < 0.047. SIGNIFICANCE OF RESULTS: Our findings indicate that PCC is associated with overall decreased medication cost in hospitalized AD patients. Additionally, receiving a PCC was related to greater use of pain medications in hospitalized dementia patients. Our study corroborates the benefits of palliative care team intervention in managing elderly hospitalized dementia patients.

Do residents need end-of-life care training?

OBJECTIVE: As medical education evolves, emphasis on chronic care management within the medical curriculum becomes essential. Because of the consistent lack of appropriate end-of-life care training, far too many patients die without the benefits of hospice care. This study explores the association between physician knowledge, training status, and level of comfort with hospice care referral of terminally ill patients. METHOD: In 2011, anonymous surveys were distributed to physicians in postgraduate years 1, 2, and 3; fellows; hospital attending physicians; specialists; and other healthcare professionals in five hospitals of a large health system in New York. Demographic comparisons were performed using χ2 and Fisher's exact tests. Spearman correlations were calculated to determine if professional status and experience were associated with comfort and knowledge discussing end-of-life topics with terminal patients. RESULTS: The sample consisted of 280 participants (46.7% response rate). Almost a quarter (22%) did not know key hospice referral criteria. Although 88% of respondents felt that knowledge of hospice care is an important competence, 53.2% still relinquished advance directives discussion to emergency room (ER) physicians. Fear of patient/family anger was the most frequently reported hospice referral barrier, although 96% of physicians rarely experienced reprisals. Physician comfort level discussing end-of-life issues and hospice referral was significantly associated with the number of years practicing medicine and professional status. SIGNIFICANCE OF RESULTS: Physicians continue to relinquish end-of-life care to ER staff and palliative care consultants. Exploring unfounded and preconceived fears associated with hospice referral needs to be integrated into the curriculum, to prepare future generations of physicians. Medical education should focus on delivering the right amount of end-of-life care training, at the right time, within the medical school and residency curriculum.

Medical orders for life-sustaining treatment: is it time yet?

OBJECTIVE: As the aging population faces complex end-of-life issues, we studied the intervals between long-term care admission and advance directive completion, and between completion and death. We also sought to determine the interdisciplinary team's compliance with documented wishes. METHOD: A cross-sectional study of 182 long-term care residents in two facilities with and without completed medical orders for life-sustaining treatment (MOLST) in the New York Metropolitan area was conducted. Demographic variables included: gender, age, ethnicity, and diagnosis. Measures included: admission date, MOLST execution date, and date of death. Resident advance directive documentation was compared with clinical intervention at time of death, including intubation and mechanical ventilation. RESULTS: Of the residents studied, 68.7% were female, 91% were Caucasian and 91.8% were ≥ 65 years of age (mean age: 83). The median time from admission to MOLST signing was 48 days. Median time from admission to MOLST signing for Caucasians was 21 days; for non-Caucasians was 229 days. Fifty-two percent of MOLST were signed by children, and 24% by residents. Of those with signed forms, 25% signed on day of admission, 37% signed within 7 days, and 47% signed within 21 days. Only 3% of residents died the day their MOLST was signed, whereas 12% died within a week, and 22% died within 30 days. Finally, among the 68 subjects who signed a MOLST and died, 87% had their wishes met. SIGNIFICANCE OF RESULTS: In this era of growing time constraints and increased regulations, medical directors of long-term care facilities and those team members caring for residents urgently need a clear and simple approach to the goals of care for their residents. The MOLST is an ideal tool in caring for older adults at the end of life, providing concrete guidance, not only with regard to do not resuscitate (DNR) and do not intubate (DNI) orders, but also for practical approaches to daily care for the interdisciplinary team.

Ethnicity, race, and advance directives in an inpatient palliative care consultation service.

OBJECTIVE: Although race and ethnic background are known to be important factors in the completion of advance directives, there is a dearth of literature specifically investigating the effect of race and ethnicity on advance directive completion rate after palliative care consultation (PCC). METHOD: A chart review of all patients seen by the PCC service in an academic hospital over a 9-month period was performed. Data were compiled using gender, race, ethnicity, religion, and primary diagnosis. For this study, advance directives were defined as: "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI). RESULTS: Of the 400 medical records reviewed, 57% of patients were female and 71.3% documented their religion as Christian. The most common documented diagnosis was cancer (39.5%). Forty-seven percent reported their race as white. White patients completed more advance directives than did nonwhite patients both before (25.67% vs. 12.68%) and after (59.36% vs. 40.84%) PCC. There was a significantly higher proportion of whites who signed an advance directive after a PCC than of nonwhites (p = 0.021); of the 139 whites who did not have an advance directive at admission, 63 signed an advance directive after a PCC compared with 186/60 nonwhites (45% vs. 32%, respectively, p = 0.021). Further analysis revealed that African Americans differed from whites in the likelihood of advance directive execution rates pre-PCC, but not post-PCC. SIGNIFICANCE OF RESULTS: This study demonstrates the impact of a PCC on the completion of advance directives, on both whites and nonwhites. The PCC Intervention significantly reduced differences between whites and African Americans in completing advance directives, which have been consistently documented in the end-of-life literature.

Electrocardiogram Monitoring Practices for Hospitalized Adults Receiving Antipsychotics: A Retrospective Cohort Study.

OBJECTIVE: Antipsychotics are frequently used for managing both acute and chronic neuropsychiatric disorders. While antipsychotics are known to be associated with increased mortality due to cardiac arrhythmia, there is a lack of consensus on the timing and frequency of electrocardiogram (ECG) monitoring.  The goal of this study was to examine current ECG monitoring practices for adults receiving antipsychotics, specifically during hospital admission. METHODS: The study involved a multisite retrospective chart review of adults admitted across 8 hospitals between January 2010 and December 2015 who received antipsychotics during hospitalization. The primary outcome was the presence of an ECG after receiving an antipsychotic. RESULTS: During the study period, there were 26,353 hospitalizations during which adults received antipsychotic medication; the average age of the patients was 61.4 years, 50.1% were female, and 64.8% were white. The average comorbidity score was 1.4 with a median length of stay of 8.3 days. Of the 26,353 patients who were hospitalized, 60.6% (n=15,977) of patients in the sample had an ECG during their hospitalization, and 41.2% (n=10,865) had the ECG following antipsychotic administration. Patients who received a follow-up ECG had a longer length of stay (median: 11.3 d) compared with those who did not receive a follow-up ECG (median: 7.0 d). Follow-up ECGs were more likely among patients who had a history of heart failure [odds ratio (OR)=1.17, 95% confidence interval (CI): 1.06-1.30, P=0.002], who were receiving multiple antipsychotics (OR=1.3, 95% CI: 1.24-1.36, P<0.001) or other QT-prolonging medications (OR=1.09, 95% CI: 1.07-1.1, P<0.001), who were receiving risperidone (OR=1.12, 95% CI: 1.004-1.25, P=0.04), and who showed an increase in QTc duration (OR per 10 ms increase=1.02, 95% CI: 1.01-1.04, P=0.003). Follow-up ECGs were less likely to be administered to patients who were receiving antipsychotics before admission (OR=0.93, 95% CI: 0.87-0.997, P=0.04). CONCLUSIONS: This study demonstrated that, in a large health system, ECG monitoring is not routinely practiced for hospitalized patients receiving antipsychotics. Further studies are needed to identify patients who would most benefit from ECG monitoring in the acute care setting.

Hospital practices and clinical outcomes associated with behavioral symptoms in persons with dementia.

BACKGROUND: Hospitalized persons living with dementia (PLWD) often experience behavioral symptoms that challenge medical care. OBJECTIVE: This study aimed to identify clinical practices and outcomes associated with behavioral symptoms in hospitalized PLWD. DESIGN: A retrospective cross-sectional study. SETTINGS AND PARTICIPANTS: The study included PLWD (65+) admitted to one of severe health system hospitals in 2019. INTERVENTION: Behavioral symptoms were defined as the presence of (1) a psychoactive medication for behavioral symptoms; (2) an order for physical restraints or constant observation; and/or (3) physician documentation of delirium, encephalopathy, or behavioral symptoms. MAIN OUTCOME AND MEASURES: Associations between behavioral symptoms and patient characteristics and hospital practices (e.g., bladder catheter) were examined. Multivariable logistic/linear regression was used to evaluate the association between behavioral symptoms and clinical outcomes (e.g., mortality). RESULTS: Of hospitalized PLWD (N = 8637), the average age was 84.5 years (IQR = 79-90), 61.7% were female, 60.1% were white, and 9.4% (n = 833) were Hispanic. Behavioral symptoms were identified in 40.6% (N = 3606) of individuals. Behavioral symptoms were significantly associated with male gender (40.3% vs. 36.9%, p = .001), white race (62.7% vs. 58.3%, p < .001), and residence in a facility prior to admission (26.6% vs. 23.7%, p < .001). Regarding hospital practices, indwelling bladder catheters (11.2% vs. 6.0%, p < .001) and dietary restriction (41.9% vs. 33.8%, p < .001) were associated with behavioral symptoms. In multivariable models, behavioral symptoms were associated with increased hospital mortality (odds ratio [OR]: 1.90, CI95%: 1.57-2.29), length of stay (parameter estimate: 2.10, p < .001), 30-day readmissions (OR: 1.14, CI95%: 1.014-1.289), and decreased discharge home (OR: 0.59, CI95%: 0.53-0.65, p < .001). CONCLUSIONS: Given the association between behavioral symptoms and poor clinical outcomes, there is an urgent need to improve the provision of care for hospitalized PLWD.

Knowledge and attitudes of health care workers regarding MOLST (Medical Orders for Life-Sustaining Treatment) implementation in long-term care facilities.

We studied the impact of knowledge and attitudes of physicians, nurses, and social workers in nursing facilities of the Medical Orders for Life Sustaining Treatment(MOLST)implementation. The results indicate that in the case of advance directives, knowledge influences care.

The impact of an end-of-life communication skills intervention on physicians-in-training.

The palliative medicine literature consistently documents that physicians are poorly prepared to help patients experience a "good death" and are often unaware of their ill patients' preferences for end-of-life care. The present study, enrolling 150 physicians, sought to improve their communication skills for end-of-life care. We found significant attitudinal changes and a greater degree of self-rated competence in delivering end-of-life care for those in the intervention group. This study used a novel approach to train physicians to be better equipped to conduct difficult goals of care conversations with patients and their families at end-of-life.

Quality-of-Care Implications of Antimicrobial Prescription Patterns for Acute Respiratory Tract Infections.

ABSTRACT: The Centers for Disease Control and Prevention estimates that half of the antibiotic prescriptions for acute respiratory tract infections (ARTIs) in ambulatory care settings are unnecessary. To better understand the quality-of-care implications of prescription patterns for ARTIs, we conducted a retrospective chart review of outpatient ARTI visits, across a large integrated health system, and examined the association of patient characteristics with receiving antimicrobials, as well as the association between receiving antimicrobials and healthcare utilization (outpatient and emergency department visits). We found that 55.4% of all ARTI outpatients were treated with antimicrobials. There was no association between patient demographics and antimicrobial prescriptions on either the first (p < .0771) or follow-up (p < .6316) visits. A lower comorbidity score was significantly associated with receiving antimicrobials (p < .0022). Patients who received antimicrobials at the first visit had significantly higher number of follow-up visits (p < .005) and more follow-up antimicrobial prescriptions (p < .0066) as compared with patients who did not receive antimicrobials at the first visit. Our results highlight the potential for clinicians to improve quality of care in ARTI management.

Improving delirium detection in intensive care units: Multicomponent education and training program.

BACKGROUND: Delirium is a common, devastating, and underrecognized syndrome in the intensive care unit (ICU). The study aimed to describe and evaluate a multicomponent education and training program utilizing a "Train-The-Trainer" (TTT) model, to improve delirium detection across a large health system. METHODS: Fourteen ICUs across nine hospitals participated in a multicomponent delirium program consisting of a 1-day workshop that included: (1) patient testimonials, (2) small group discussions, (3) didactics, and (4) role-playing. Additionally, four ICUs received direct observation/training via telehealth (tele-delirium training). The Kirkpatrick model was used for program evaluation in a pre/post-test design. RESULTS: A 1-day delirium workshop was held at two time points and included 73 ICU nurses. Of the 65 nurses completing the post-workshop satisfaction survey, most (46.2) had >10 years of clinical experience, and no or minimal delirium training (69.2%). All nurses (100%) identified lack of knowledge as a barrier to delirium detection, while time constraints and lack of importance accounted for only 25%. Overall, nurses rated the workshop positively (excellent 66.7%, and very good 23.3%), and likely to change practice (definitely 73.3% and very likely 15.0%). All validated Confusion Assessment Method for the ICU (CAM-ICU) cases demonstrated improvement in number of correct responses. Delirium detection across the health system improved from 9.1% at baseline to 21.2% in ICUs that participated in the workshop and 30.1% in those ICUs that also participated in the tele-delirium training (p = 0.005). CONCLUSION: A multicomponent delirium education and training program using a TTT model was rated positively, improved CAM-ICU knowledge, and increased delirium detection.

Factors influencing older adults to complete advance directives.

OBJECTIVE: The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults. METHOD: Direct interviews of hospitalized and community-dwelling cognitively intact patients > 65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives. We identified five variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables. RESULTS: Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p < 0.0002), age (p < 0.0161), race (p < 0.0001), education (p < 0.0039), and religion (p < 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3, p < 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2, p < 0.0001), having undergone major surgery (OR 6.3, p < 0.0017), female gender (OR 11.1, p < 0.0001) and increasing age (76-85 vs. 59-75: OR 3.4, p < 0.0543; < 85 vs. 59-75: OR 6.3, p < 0.0263). SIGNIFICANCE OF RESULTS: This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.

Preoperative Noninvasive Cardiac Testing in Older Adults with Hip Fracture: A Multi-Site Study.

BACKGROUND/OBJECTIVES: For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture. DESIGN: Retrospective chart review. SETTING: Seven hospitals (three tertiary, four community) within a large health system. PARTICIPANTS: Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married). MEASUREMENTS: Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality. RESULTS: Although 34.3% (n = 370) had a preoperative TTE, .7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] = .8-1.8 days), median LOS was 5.3 days (IQR = 4.2-7.2 days), and in-hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P < .001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P < .001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P < .001). No difference in mortality was found between patients with and without a preoperative TTE. CONCLUSION: This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population. J Am Geriatr Soc 68:1690-1697, 2020.

A Telehealth-Delivered Pulmonary Rehabilitation Intervention in Underserved Hispanic and African American Patients With Chronic Obstructive Pulmonary Disease: A Community-Based Participatory Research Approach.

BACKGROUND: Although home telemonitoring (TM) is a promising approach for patients managing their chronic disease, rehabilitation using home TM has not been tested for use with individuals living with chronic obstructive pulmonary disease (COPD) residing in underserved communities. OBJECTIVE: This study aimed to analyze qualitative data from focus groups with key stakeholders to ensure the acceptability and usability of the TM COPD intervention. METHODS: We utilized a community-based participatory research (CBPR) approach to adapt a home TM COPD intervention to facilitate acceptability and feasibility in low-income African American and Hispanic patients. The study engaged community stakeholders in the process of modifying the intervention in the context of 2 community advisory board meetings. Discussions were audio recorded and professionally transcribed and lasted approximately 2 hours each. Structural coding was used to mark responses to topical questions in interview guides. RESULTS: We describe herein the formative process of a CBPR study aimed at optimizing telehealth utilization among African American and Latino patients with COPD from underserved communities. A total of 5 major themes emerged from qualitative analyses of community discussions: equipment changes, recruitment process, study logistics, self-efficacy, and access. The identification of themes was instrumental in understanding the concerns of patients and other stakeholders in adapting the pulmonary rehabilitation (PR) home intervention for acceptability for patients with COPD from underserved communities. CONCLUSIONS: These findings identify important adaptation recommendations from the stakeholder perspective that should be considered when implementing in-home PR via TM for underserved COPD patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT03007485; https://clinicaltrials.gov/ct2/show/NCT03007485.