Implementation of an evidence-based medicine curriculum in a fellowship program: Can it influence clinical practice?

While evidence-based medicine (EBM) curricula improves knowledge scores, correlation with physician behavior, and patient outcomes are not clear. We established an EBM curriculum for Geriatrics and Palliative Medicine fellows that included didactic teaching, opportunity for deliberate practice and presentation, and coaching and feedback from faculty experts, to determine the impact on self-assessed confidence in teaching EBM, Practice-Based Learning and Improvement (PBLI) competency rating and patient care decisions. Seventeen fellows at a New York City academic medical center participated during 2014-2015 academic year. We analyzed pre-/posttest surveys for self-assessed confidence in teaching EBM concepts, EBM worksheets for content of clinical questions and impact on patient care, and PBLI competency ratings for overall impact. Posttest survey indicated that fellows' self-assessed confidence in teaching EBM increased significantly. While most found Journal Club discussions and EBM case conferences valuable, only 36% of fellows found EBM worksheets completion to be good use of time (average completion time 89 minutes). EBM worksheets helped reinforce or change plan of care in 32 out of 50 cases. There was no impact on end-of-the-year PBLI ratings. This curriculum, integrating didactic, self-directed and peer learning with objective feedback, increased self-assessed confidence in teaching EBM, and influenced patient care plans.

Implementation and Effectiveness of Cognitive Behavioral Therapy for Insomnia in Geriatric Primary Care.

OBJECTIVES: We evaluated a plan for implementation and effectiveness of cognitive behavioral therapy for insomnia (CBT-I) in geriatric primary care by a geropsychologist. METHODS: The flow of referrals to a geropsychologist was tracked and, among those eligible and interested in participating, success in deprescribing sleep medications and the effectiveness of CBT-I were documented. RESULTS: Seventy patients were referred for evaluation of whom 62 were eligible for CBT-I; 34 began CBT-I and 29 completed a full course of treatment. Almost two-thirds of treatment completers were the "old old" (76-84 years) and "oldest old" (85-93 years) with multiple medical problems. Most treatment completers taking sleep medications had them deprescribed at the beginning of treatment and, one year after treatment, did not have them re-prescribed. After CBT-I, two-thirds of patients met the insomnia severity index criteria for response; and three-fifths for remission from insomnia. Further, most patients had sustained improvement in their target insomnia symptom(s) and sleep efficiency. CONCLUSIONS: CBT-I can be implemented in geriatric primary care with successful deprescribing of sleep medications and meaningful improvement in symptoms of insomnia in a group of older adults of advanced age with multiple medical problems. CLINICAL IMPLICATIONS: Clinical gerontologists can play an important role in improving late life insomnia.

Modifiable factors associated with postoperative delirium after hip fracture repair: An age-stratified retrospective cohort study.

BACKGROUND: Postoperative delirium in hip fracture patients is common and is associated with substantial morbidity and consumption of resources. OBJECTIVE: Using data from the USA, we aimed to examine the relationship between postoperative delirium and (modifiable) peri-operative factors mentioned in the American Geriatrics Society Best Practice Statement on Postoperative Delirium in Older Adults, stratified by 'young old' (<80 years) and 'old-old' (≥80 years) categories. DESIGN: Retrospective cohort study from 2006 to 2016. SETTING: Population-based claims data from the USA. PARTICIPANTS: Patients undergoing 505 152 hip fracture repairs between 2006 and 2016 as recorded in the Premier Healthcare Database. MAIN OUTCOMES AND MEASURES: The main outcome was postoperative delirium; modifiable factors of interest were peri-operative opioid use (high, medium or low; <25th, 25 to 75th or >75th percentile of oral morphine equivalents), anaesthesia type (general, neuraxial, both), use of benzodiazepines (long acting, short acting, both), pethidine, nonbenzodiazepine hypnotics, ketamine, corticosteroids and gabapentinoids. Multilevel models assessed associations between these factors and postoperative delirium, in the full cohort, and separately in those aged less than 80 and at least 80 years. Odds ratios (ORs) and Bonferroni-adjusted 95% confidence intervals (95% CIs) are reported. RESULTS: Overall, postoperative delirium incidence was 15.7% (n = 79 547). After adjustment for relevant covariates, the use of long-acting (OR 1.82, CI 1.74 to 1.89) and combined short and long-acting benzodiazepines (OR 1.56, CI 1.48 to 1.63) and ketamine (OR 1.09, CI 1.03 to 1.15), in particular, was associated with increased odds for postoperative delirium, while neuraxial anaesthesia (OR 0.91 CI 0.85 to 0.98) and opioid use (OR 0.95, CI 0.92 to 0.98 and OR 0.88, CI 0.84 to 0.92 for medium and high dose compared with low dose) were associated with lower odds; all P < 0.05. When analysing data separately by age group, effects of benzodiazepines persisted, while opioid use was only relevant in those aged less than 80 years. CONCLUSION: We identified modifiable factors associated with postoperative delirium incidence among patients undergoing hip fracture repair surgery.

A model for integrating the assessment and management of geriatric syndromes into internal medicine continuity practice: 5-year report.

A geriatric ambulatory curriculum was created to improve internal medicine residents' care of geriatric patients. Second-year residents met for a 3-hour session weekly for 4 consecutive weeks during a block rotation with faculty geriatricians for a curriculum focused on dementia, falls, and urinary incontinence. After a 1-hour case-based didactic session, residents applied learned content and concepts to patient consultations. Consultative encounters were precepted by faculty and shared with the team. After completing our curriculum, residents reported knowledge acquired and enhanced evaluation and management skills of these three syndromes and were more likely to use all recommended screening tests in future practice. This article describes the process and strategies guiding development of a successful ambulatory geriatric curriculum model that can be embedded into preexisting internal medicine clinics to help future internists to better manage these and other common geriatric syndromes.

A framework for crafting clinical practice guidelines that are relevant to the care and management of people with multimorbidity.

Many patients of all ages have multiple conditions, yet clinicians often lack explicit guidance on how to approach clinical decision-making for such people. Most recommendations from clinical practice guidelines (CPGs) focus on the management of single diseases, and may be harmful or impractical for patients with multimorbidity. A major barrier to the development of guidance for people with multimorbidity stems from the fact that the evidence underlying CPGs derives from studies predominantly focused on the management of a single disease. In this paper, the investigators from the Improving Guidelines for Multimorbid Patients Study Group present consensus-based recommendations for guideline developers to make guidelines more useful for the care of people with multimorbidity. In an iterative process informed by review of key literature and experience, we drafted a list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes. The recommended approaches address consideration of coexisting conditions at all major steps in CPG development, from nominating and scoping the topic, commissioning the work group, refining key questions, ranking importance of outcomes, conducting systematic reviews, assessing quality of evidence and applicability, summarizing benefits and harms, to formulating recommendations and grading their strength. The list of issues and recommendations was reviewed and refined iteratively by stakeholders. This framework acknowledges the challenges faced by CPG developers who must make complex judgments in the absence of high-quality or direct evidence. These recommendations require validation through implementation, evaluation and refinement.

Reconsidering the approach to prevention recommendations for older adults.

The U.S. Preventive Services Task Force (USPSTF) bases its recommendations on an evidence-based model of clinical prevention that focuses on specific diseases, well-defined preventive interventions, and evidence of improved health outcomes. Applying this model to prevention for very old patients has been problematic for several reasons: Many geriatric disorders have multiple risk factors, interventions, and expected outcomes; older adults are not often represented in clinical trials; and important outcomes may not be measured and reported in ways that are conducive to evidence synthesis and interpretation. In 2005, the USPSTF convened a geriatrics workgroup to refine USPSTF methodology and processes to better address the preventive needs of older adults. The USPSTF has begun to apply these new approaches to the review and recommendation on interventions to prevent falls in older adults.

Using Electronic Health Records to Enhance Predictions of Fall Risk in Inpatient Settings.

BACKGROUND: Falls are the most common adverse events of hospitalized adults. Traditional validated assessment tools have limited ability to accurately detect patients at high risk for falls. The researchers aim to develop an automated comprehensive risk score to enhance the identification of patients at high risk for falls and examine its effectiveness. METHODS: The enhanced fall algorithm (EFA) was developed from 171,515 hospitalizations and 2,659 falls, in an academic medical center, using hierarchical logistic regression. Routine nursing assessments, labs, medications, demographics, and patients' location during their hospitalization were gathered from the electronic health record (EHR). RESULTS: The fall rate was 2.8 per 1,000 patient-days. Morse fall score was the strongest predictor of falls (odds ratio = 7.16, 95% confidence interval = 6.48-7.91), with a model discrimination c-statistic of 0.687. By adding patient demographics, chronic conditions, lab values, and medications, and controlling for patient clustering within units, predication was enhanced and model discrimination increased to 0.805. By applying the enhanced model, we observed redistribution of patient by risk: low-risk group increased from 52.8% to 66.5%, and the high-risk group decreased from 28.0% to 16.2%, with an increase of fall detection from 3.1% to 5.1%. CONCLUSION: The EFA redistributes and identifies patients at high risk more accurately than the Morse score alone, decreasing the population of high-risk patients without increasing the rate of falls over time. The EFA requires no addition data collection and automatically updates the patient's fall risk based on new inputs in the EHR.

House staff member awareness of older inpatients' risks for hazards of hospitalization.

BACKGROUND: Many hospitalized older adults develop iatrogenic complications unrelated to their presenting diagnoses that can result in longer hospitalizations, functional impairment, or unanticipated medical or surgical interventions. These complications are often referred to as "hazards of hospitalization" and include delirium, malnutrition, urinary incontinence, pressure ulcers, depression, falls, restraint use, infection, functional decline, adverse drug effects, and death. The aims of this study were to assess house staff member awareness of older patients' risk factors for developing hazards of hospitalization and to determine areas in which interventions may help improve recognition. METHODS: A cross-sectional study was performed, from December 1, 1999, through August 31, 2002, of internal medicine and medicine or pediatric house staff members and their patients from 4 medical units at Mount Sinai Medical Center. Each house staff member completed a 23-item survey on 3 of their recently admitted patients. These patients and, if appropriate, their surrogates were interviewed by the study investigator within 2 hours of the completion of the house staff survey. House staff member responses are compared with those obtained by the study investigator. The completed house staff surveys were compared with the reference standard, and areas of agreement and disagreement were noted. RESULTS: Eighty-six house staff teams, consisting of 1 intern and 1 resident (in either the second or third postgraduate year), and 105 patients were enrolled in the study. The house staff members were in frank disagreement or poor agreement with the reference standard in knowing the following: how well their patients were oriented to place or how long they had been hospitalized; patients' quality of sleep, presence of pain, history of falls, mood, quantity of food intake, and use of hearing aids, glasses, or an ambulation assistive device when at home; and the name of their patients' primary care physicians. CONCLUSIONS: This study showed that internal medicine house staff members are not aware of many of their patients' risk factors for developing the hazards of hospitalization. Some of these deficits are glaring, particularly the lack of awareness of patients' orientation to place and time (duration of hospitalization), presence of pain, and the identity of their primary care physician. It will likely take education and cultural change to improve this performance. Such improvement could be accomplished as part of 3 of the Accreditation Council for Graduate Medical Education competencies: interpersonal communication, patient care, and systems-based practice. Such a process might improve not only house staff member awareness but also patient outcomes, since interdisciplinary communication and interventions are key to preventing the hazards of hospitalization.

Efficient and accurate measurement of physical restraint use in acute care.

OBJECTIVES: Describe and evaluate a method for assessing whether physical restraint prevalence differs by timing and frequency of data collection and to determine the minimum period of observation necessary to provide accurate prevalence estimates on both Intensive Care Unit (ICU) and medical-surgical units. DESIGN: Two-period, cross-sectional design with repeated observations in year 1 for 18 consecutive days and in year 2 for 21 consecutive days with method modifications. SETTING: 400-bed urban teaching hospital. PARTICIPANTS: All beds on general medical, surgical, and intensive care units. MEASUREMENT: Direct observation of patients, nurse interview, and medical record review conducted by trained observers. RESULTS: There were no significant differences in mean restraint use prevalence rates comparing: (a) morning and evening periods; (b) weekdays and weekend days; and (c) observation periods of 7, 14, or 21 consecutive days or for 7 days using every 3rd day on either medical-surgical units or ICUs. Analyses using data from an increasing number of days of observation indicates that the mean prevalence rate stabilizes after 16 days. There were larger mean differences for comparisons on ICU-ventilator units and lack of significant differences may be due to low statistical power. CONCLUSION: Direct observation by trained observers, supplemented by nurse report and medical record documentation over brief monitoring periods, results in accurate, nonintrusive, cost-efficient estimates of physical restraint prevalence. As few as seven consecutive or nonconsecutive days in measuring restraint prevalence is sufficient to obtain accurate estimates, although the number of days may vary depending on patient mix and unit type.

Introducing Aquifer Geriatrics, the American Geriatrics Society National Online Curriculum.

Aquifer Geriatrics, formerly web-based Geriatrics Education Modules, was initially developed through Donald W. Reynolds Foundation funding, and is now the national curriculum of the American Geriatrics Society and the Association of Directors of Geriatric Academic Programs. Aquifer Geriatrics consists of 26 evidence-based, peer-reviewed, online case-based modules based on the Association of American Medical Colleges/John A. Hartford Foundation Minimum Geriatrics Competencies for Medical Students and is available by subscription at www.aquifer.org/courses. This curriculum aims to help address the national shortage of geriatrics educators, complement current teaching, bridge content gaps in geriatrics education, and standardize geriatrics-focused educational content. This report will describe the development of Aquifer Geriatrics, highlight best practices to incorporate cases in a variety of teaching settings, describe teaching methods that utilize the curriculum to create a robust experience for learners, and address the cost of obtaining the curriculum. J Am Geriatr Soc 67:811-817, 2019.

Application of assessing care of vulnerable elders-3 quality indicators to patients with advanced dementia and poor prognosis.

OBJECTIVES: To use a formal decision-making strategy to reach clinically appropriate, internally consistent decisions on the application of quality indicators (QIs) to vulnerable elders (VEs) with advanced dementia (AD) or poor prognosis (PP). DESIGN: Using a conceptual model that classifies QIs principally by aim and burden of the care process, 12 clinical experts rated whether each Assessing Care of Vulnerable Elders-3 (ACOVE-3) QI should be applied in evaluating quality of care for older persons with AD or PP. QI exclusions were assessed for each of the 26 conditions and by whether these conditions were mainly medical (e.g., diabetes mellitus), geriatric (e.g., falls), or crosscutting processes of care (e.g., pain management). QI exclusions were also identified for older persons who decided against hospitalization or surgery. RESULTS: Of 392 ACOVE-3 QIs, 140 (36%) were excluded for patients with AD and 135 (34%) for patients with PP; 57% of QIs focusing on medical conditions were excluded from patients with AD and 53% from patients with PP, whereas only 20% of QIs for geriatric conditions were excluded from AD and 15% from PP. All QIs with care processes judged to carry a heavy burden were excluded; 86% of moderate-burden QIs were excluded from AD and 92% from PP. All QIs aimed at long-term goals were excluded; 83% of intermediate-term goal QIs were excluded from AD and 98% from PP. Individuals holding a preference to forgo hospitalization or surgery would be excluded from 7% of potentially applicable QIs. CONCLUSION: Measurement of quality of care for VEs with AD, PP, and less-aggressive care preferences should include only a subset of the ACOVE-3 QIs, largely those whose burden is light and whose goal is continuity or short-term improvement or prevention.