Reducing Care Overuse in Older Patients Using Professional Norms and Accountability : A Cluster Randomized Controlled Trial.

BACKGROUND: Effective strategies are needed to curtail overuse that may lead to harm. OBJECTIVE: To evaluate the effects of clinician decision support redirecting attention to harms and engaging social and reputational concerns on overuse in older primary care patients. DESIGN: 18-month, single-blind, pragmatic, cluster randomized trial, constrained randomization. (ClinicalTrials.gov: NCT04289753). SETTING: 60 primary care internal medicine, family medicine and geriatrics practices within a health system from 1 September 2020 to 28 February 2022. PARTICIPANTS: 371 primary care clinicians and their older adult patients from participating practices. INTERVENTION: Behavioral science-informed, point-of-care, clinical decision support tools plus brief case-based education addressing the 3 primary clinical outcomes (187 clinicians from 30 clinics) were compared with brief case-based education alone (187 clinicians from 30 clinics). Decision support was designed to increase salience of potential harms, convey social norms, and promote accountability. MEASUREMENTS: Prostate-specific antigen (PSA) testing in men aged 76 years and older without previous prostate cancer, urine testing for nonspecific reasons in women aged 65 years and older, and overtreatment of diabetes with hypoglycemic agents in patients aged 75 years and older and hemoglobin A1c (HbA1c) less than 7%. RESULTS: At randomization, mean clinic annual PSA testing, unspecified urine testing, and diabetes overtreatment rates were 24.9, 23.9, and 16.8 per 100 patients, respectively. After 18 months of intervention, the intervention group had lower adjusted difference-in-differences in annual rates of PSA testing (-8.7 [95% CI, -10.2 to -7.1]), unspecified urine testing (-5.5 [CI, -7.0 to -3.6]), and diabetes overtreatment (-1.4 [CI, -2.9 to -0.03]) compared with education only. Safety measures did not show increased emergency care related to urinary tract infections or hyperglycemia. An HbA1c greater than 9.0% was more common with the intervention among previously overtreated diabetes patients (adjusted difference-in-differences, 0.47 per 100 patients [95% CI, 0.04 to 1.20]). LIMITATION: A single health system limits generalizability; electronic health data limit ability to differentiate between overtesting and underdocumentation. CONCLUSION: Decision support designed to increase clinicians' attention to possible harms, social norms, and reputational concerns reduced unspecified testing compared with offering traditional case-based education alone. Small decreases in diabetes overtreatment may also result in higher rates of uncontrolled diabetes. PRIMARY FUNDING SOURCE: National Institute on Aging.

COVID-19 Vaccination Coverage, and Rates of SARS-CoV-2 Infection and COVID-19-Associated Hospitalization Among Residents in Nursing Homes - National Healthcare Safety Network, United States, October 2023-February 2024.

Nursing home residents are at increased risk for developing severe COVID-19. Nursing homes report weekly facility-level data on SARS-CoV-2 infections, COVID-19-associated hospitalizations, and COVID-19 vaccination coverage among residents to CDC's National Healthcare Safety Network. This analysis describes rates of incident SARS-CoV-2 infection, rates of incident COVID-19-associated hospitalization, and COVID-19 vaccination coverage during October 16, 2023-February 11, 2024. Weekly rates of SARS-CoV-2 infection ranged from 61.4 to 133.8 per 10,000 nursing home residents. The weekly percentage of facilities reporting one or more incident SARS-CoV-2 infections ranged from 14.9% to 26.1%. Weekly rates of COVID-19-associated hospitalization ranged from 3.8 to 7.1 per 10,000 residents, and the weekly percentage of facilities reporting one or more COVID-19-associated hospitalizations ranged from 2.6% to 4.7%. By February 11, 2024, 40.5% of nursing home residents had received a dose of the updated 2023-2024 COVID-19 vaccine that was first recommended in September 2023. Although the peak rate of SARS-CoV-2 infection among nursing home residents was lower during the 2023-24 respiratory virus season than during the three previous respiratory virus seasons, nursing home residents continued to be disproportionately affected by SARS-CoV-2 infection and related severe outcomes. Vaccination coverage remains suboptimal in this population. Ongoing surveillance for SARS-CoV-2 infections and COVID-19-associated hospitalizations in this population is necessary to develop and evaluate evidence-based interventions for protecting nursing home residents.

Development of High-Risk Geriatric Polypharmacy Electronic Clinical Quality Measures and a Pilot Test of EHR Nudges Based on These Measures.

BACKGROUND: Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms. OBJECTIVE: To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing. DESIGN: We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019. PARTICIPANTS: Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot. MAIN MEASURES: Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease. INTERVENTIONS: Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a "commitment nudge" that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a "justification nudge" that asked for a reason when high-risk polypharmacy was present. One practice received both. KEY RESULTS: Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%). CONCLUSIONS: EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing.

Development and evaluation of a simulation-based mastery learning maintenance of certification course.

BACKGROUND/OBJECTIVES: To develop and evaluate a post-acute care simulation-based mastery learning (SBML) continuing medical education (CME)/maintenance of certification (MOC) procedure course. DESIGN: Pretest-posttest study of the SBML intervention. SETTING: A 2-day post-acute care procedures course. PARTICIPANTS: Sixteen practicing clinicians (5 physicians,11 advanced practice providers). Participants engaged in a skills pretest on knee aspiration/injection, gastrostomy tube removal/replacement, tracheostomy tube exchange, and basic suturing using a checklist created for each procedure. Participants received a didactic on each procedure followed by deliberate practice with feedback. Using the same checklists, participants completed a skills posttest and were required to meet a minimum passing standard (MPS) to obtain CME/MOC credit. MEASUREMENTS: The MPS for each skills checklist was determined by a multidisciplinary panel of 11 experts. Participants completed surveys on procedure self-confidence and a course evaluation. RESULTS: There was statistically significant improvement between pre- and posttests for all four procedures (p < .001). All participants were able to meet or exceed the MPS for each skill during the 2-day course. Participants' self-confidence regarding each procedure improved significantly (p < .001). CONCLUSION: An SBML training course granting CME/MOC credit for post-acute care providers significantly improves performance of knee aspiration/injection, gastrostomy tube removal/replacement, tracheostomy tube exchange, and basic suturing.

Examining primary care physician rationale for not following geriatric choosing wisely recommendations.

BACKGROUND: The objective is to understand why physicians order tests or treatments in older adults contrary to published recommendations. METHODS: Participants: Physicians above the median for ≥ 1 measures of overuse representing 3 Choosing Wisely topics. MEASUREMENTS: Participants evaluated decisions in a semi-structured interview regarding: 1) Screening men aged ≥ 76 with prostate specific antigen 2) Ordering urine studies in women ≥ 65 without symptoms 3) Overtreating adults aged ≥ 75 with insulin or oral hypoglycemic medications. Two investigators independently coded transcripts using qualitative analysis. RESULTS: Nineteen interviews were conducted across the three topics resulting in four themes. First, physicians were aware and knowledgeable of guidelines. Second, perceived patient preference towards overuse influenced physician action even when physicians felt strongly that testing was not indicated. Third, physicians overestimated benefits of a test and underemphasized potential harms. Fourth, physicians were resistant to change when patients appeared to be doing well. CONCLUSIONS: Though physicians expressed awareness to avoid overuse, deference to patient preferences and the tendency to distort the chance of benefit over harm influenced decisions to order testing. Approaches for decreasing unnecessary testing must account for perceived patient preferences, make the potential harms of overtesting salient, and address clinical inertia among patients who appear to be doing well.

Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement.

IMPORTANCE: The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood. OBJECTIVE: To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults. DESIGN: Retrospective analysis of overall means and clinician-level variation in performance on three new measures. SUBJECTS: Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017. MEASURES: Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication. RESULTS: Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively. CONCLUSIONS: Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.

SGIM-AMDA-AGS Consensus Best Practice Recommendations for Transitioning Patients' Healthcare from Skilled Nursing Facilities to the Community.

We assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This work was sponsored through a grant from the Association of Subspecialty Physicians (ASP). Members of the team mapped the process of discharging patients from a skilled nursing facility into the community and subsequent care of their outpatient PCP. Four areas of process improvement were identified, building on the prior work of the AMDA Transitions of Care Committee and the experiences of the team members. The team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish. The goal of these consensus-based recommended best practices is to provide a safe and high-quality transition for patients moving between the care of their SNF physician and PCP.

Development and pilot testing of EHR-nudges to reduce overuse in older primary care patients.

BACKGROUND: Unnecessary testing and treatment of common conditions in older adults can lead to significant morbidity and mortality. The primary objective of this study was to develop and pilot test a set of clinical decision support (CDS) alerts informed by social psychology to address overuse in three areas related to ambulatory care of older adults. METHODS: We developed three electronic health record (EHR) CDS alerts to address overuse and pilot tested them from January 17, 2019 to July 17, 2019. We enrolled 14 primary care physicians from three practices within a large health system who cared for adults aged 65 years and older. Three measures of overuse applied to patients meeting the following criteria: ordering of prostate-specific antigen (PSA) for prostate cancer screening in adult men aged 76 years and older, ordering of urinalysis or urine cultures (UA or UC) for non-specific reasons to identify bacteriuria in women aged 65 years and older, and overtreatment of diabetes with insulin or oral hypoglycemic medications in adults aged at 75 years and older (DM). Clinicians received CDS alerts when criteria for any of the three overuse measures were met. We then surveyed clinicians to evaluate their experience with the CDS alerts. RESULTS: The number of clinical encounters that triggered CDS alerts was 19 for PSA, 48 for UA/UC and 128 for DM. For PSA encounters, 4 (21%) orders were not performed after the alert. In the UA/UC encounters 29 (60%) orders were not performed after the alert. For the DM encounters, 21 (34%) had diabetes therapy reduced following the alert. Survey respondents indicated that the alerts were clinically accurate and sometimes led them to change their clinical action. CONCLUSIONS: These CDS alerts were feasible to implement and may minimize unnecessary testing and treatment of common conditions in older adults.

Reliability of nonlocalizing signs and symptoms as indicators of the presence of infection in nursing-home residents.

Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug-drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.

A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions.

BACKGROUND: Requiring accountable justifications-visible, clinician-recorded explanations for not following a clinical decision support (CDS) alert-has been used to steer clinicians away from potentially guideline-discordant decisions. Understanding themes from justifications across clinical content areas may reveal how clinicians rationalize decisions and could help inform CDS alerts. METHODS: We conducted a qualitative evaluation of the free-text justifications entered by primary care physicians from three pilot interventions designed to reduce opioid prescribing and, in older adults, high-risk polypharmacy and overtesting. Clinicians encountered alerts when triggering conditions were met within the chart. Clinicians were asked to change their course of action or enter a justification for the action that would be displayed in the chart. We extracted all justifications and grouped justifications with common themes. Two authors independently coded each justification and resolved differences via discussion. Three physicians used a modified Delphi technique to rate the clinical appropriateness of the justifications. RESULTS: There were 560 justifications from 50 unique clinicians. We grouped these into three main themes used to justify an action: (1) report of a particular diagnosis or symptom (e.g., for "anxiety" or "acute pain"); (2) provision of further contextual details about the clinical case (e.g., tried and failed alternatives, short-term supply, or chronic medication); and (3) noting communication between clinician and patient (e.g., "risks and benefits discussed"). Most accountable justifications (65%) were of uncertain clinical appropriateness. CONCLUSION: Most justifications clinicians entered across three separate clinical content areas fit within a small number of themes, and these common rationales may aid in the design of effective accountable justification interventions. Justifications varied in terms of level of clinical detail. On their own, most justifications did not clearly represent appropriate clinical decision making.

Design of Behavioral Economic Applications to Geriatrics Leveraging Electronic Health Records (BEAGLE): A pragmatic cluster randomized controlled trial.

BACKGROUND: Overtesting and treatment of older patients is common and may lead to harms. The Choosing Wisely campaign has provided recommendations to reduce overtesting and overtreatment of older adults. Behavioral economics-informed interventions embedded within the electronic health record (EHR) have been shown to reduce overuse in several areas. Our objective is to conduct a parallel arm, pragmatic cluster-randomized trial to evaluate the effectiveness of behavioral-economics-informed clinical decision support (CDS) interventions previously piloted in primary care clinics and designed to reduce overtesting and overtreatment in older adults. METHODS/DESIGN: This trial has two parallel arms: clinician education alone vs. clinician education plus behavioral-economics-informed CDS. There are three co-primary outcomes for this trial: (1) prostate-specific antigen (PSA) screening in older men, (2) urine testing for non-specific reasons in older women, and (3) overtreatment of diabetes in older adults. All eligible primary care clinics from a large regional health system were randomized using a modified constrained randomization process and their attributed clinicians were included. Clinicians were recruited to complete a survey and educational module. We randomized 60 primary care clinics with 374 primary care clinicians and achieved adequate balance between the study arms for prespecified constrained variables. Baseline annual overuse rates for the three co-primary outcomes were 25%, 23%, and 17% for the PSA, urine, and diabetes measures, respectively. DISCUSSION: This trial is evaluating behavioral-economics-informed EHR-embedded interventions to reduce overuse of specific tests and treatments for older adults. The study will evaluate the effectiveness and safety of these interventions.

Description of antibiotic use variability among US nursing homes using electronic health record data.

Background: Antibiotics are frequently prescribed in nursing homes; national data describing facility-level antibiotic use are lacking. The objective of this analysis was to describe variability in antibiotic use in nursing homes across the United States using electronic health record orders. Methods: A retrospective cohort study of antibiotic orders for 309,884 residents in 1,664 US nursing homes in 2016 were included in the analysis. Antibiotic use rates were calculated as antibiotic days of therapy (DOT) per 1,000 resident days and were compared by type of stay (short stay ≤100 days vs long stay >100 days). Prescribing indications and the duration of nursing home-initiated antibiotic orders were described. Facility-level correlations of antibiotic use, adjusting for resident health and facility characteristics, were assessed using multivariate linear regression models. Results: In 2016, 54% of residents received at least 1 systemic antibiotic. The overall rate of antibiotic use was 88 DOT per 1,000 resident days. The 3 most common antibiotic classes prescribed were fluoroquinolones (18%), cephalosporins (18%), and urinary anti-infectives (9%). Antibiotics were most frequently prescribed for urinary tract infections, and the median duration of an antibiotic course was 7 days (interquartile range, 5-10). Higher facility antibiotic use rates correlated positively with higher proportions of short-stay residents, for-profit ownership, residents with low cognitive performance, and having at least 1 resident on a ventilator. Available facility-level characteristics only predicted a small proportion of variability observed (Model R2 version 0.24 software). Conclusions: Using electronic health record orders, variability was found among US nursing-home antibiotic prescribing practices, highlighting potential opportunities for targeted improvement of prescribing practices.

Facilitators and challenges experienced by nursing homes enrolling in the CDC national health care safety network.

BACKGROUND: Standardized measurement of health care-associated infections is essential to improving nursing home (NH) resident safety, however voluntary enrollment of NHs in Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) requires several steps. We sought to prospectively identify NH structural, process or staff characteristics that affect enrollment and data submission among a cohort of NHs receiving facilitated implementation. METHODS: The evaluation employed a mixed methods approach. The meta-theoretical Consolidated Framework for Implementation Research was used to analyze reported facilitators and challenges. Primary and secondary outcomes were time to NHSN enrollment and data submission, respectively. RESULTS: Of 36 participating NHs, 27 (75%) completed NHSN enrollment and 21 (58%) submitted 1 or more months of infection data during the 8-month study period. Mean days to complete enrollment was 82 (standard deviation [SD] = 24, range = 51-139) and days to first data submission was 112 (SD = 45, range = 71-245). Characteristics of NH staff liaisons associated with shorter time to enrollment included infection prevention and control knowledge, personal confidence, and responsibility for infection prevention and control activities. Facility characteristics were not associated with outcomes. DISCUSSION: Time to NHSN enrollment and submission related more to characteristics of the person leading the process than to characteristics of the NH. CONCLUSIONS: External partnerships that provide real-time support and resources are important assets in promoting successful NH participation in NHSN.

The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety Trial 1 (AESOPS-1): Electronic health record nudges.

BACKGROUND: There is a lack of evidence that long-term opioid use offers benefit for noncancer pain and an abundance of evidence of harm. Despite clinical guidelines and education, prescribing continues at a higher rate than before the opioids crisis. The objective of trial 1 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-1) is to discourage unnecessary opioid prescribing in primary care by applying "behavioral insights"-empirically-tested social and psychological interventions that affect choice. METHODS: AESOPS-1 randomizes primary care clinics in Illinois and California to behavioral intervention or control. Both arms receive opioid guideline education. Clinics randomized to the behavioral intervention arm receive nudges within the electronic health record (EHR) including: 1) an "accountable justification" entered in the chart, 2) a precommitment to address high-risk prescriptions, and 3) a "PainTracker" that broadens discussions about pain. The control arm receives no EHR-based intervention. The primary outcome is the change in weekly milligram morphine equivalents (MME) prescribed. The secondary outcome is the change in the proportion of patients prescribed at least 50 daily MME. To evaluate these outcomes, we will use a difference-in-differences mixed-effects regression model on clinician MME weekly or daily dose. The analysis will be "intent-to-treat." The intervention period is 18-months, with a 6-month follow-up period to measure persistence of effects. DISCUSSION: The AESOPS-1 trial will evaluate the effect of EHR-based interventions in reducing noncancer opioid prescribing in primary care. AESOPS-1 may demonstrate practical and scalable strategies to lower unnecessary population exposure to opioids.

COVID-19 exposures and infection control among home care agencies.

BACKGROUND AND OBJECTIVES: Home care agencies (HCAs) provide caregivers, who perform an important role in maintaining the health and well-being of older adults. However, during the COVID-19 pandemic, paid caregivers had the potential to inadvertently spread COVID-19. We sought to characterize the effects of COVID-19 on HCAs and examine HCAs' infection prevention and control (IPC) policies. RESEARCH DESIGN AND METHODS: This was a qualitative analysis of data collected from a national survey of HCAs. Surveys were e-mailed to members of a national HCA association on March 18, 2020. Questions included queries on demographics, COVID-19 exposures, effects of COVID-19, and IPC protocols. RESULTS: 1204 HCAs responded with an average census of 96.2 (5-2800) patients daily. Across 36 states, 238 HCAs reported COVID-19 cases or exposures among caregivers. HCAs experienced challenges related to changing patient needs (e.g. decreased caregiver requests), staffing shortages (e.g., fear of COVID-19, inability to train caregivers), and management issues (e.g., inability to obtain supplies). ICP protocols varied in how HCAs followed recommended guidelines, responded to COVID-19 exposures, performed infection surveillance, and implemented precautions. Additionally, HCAs had varying policies for caregiver PTO. CONCLUSIONS: HCAs experienced COVID-19 exposures and/or cases early in the pandemic. HCAs identified staffing and PPE shortages, and lack of IPC guidance as challenges. Although caregivers are providing essential care for millions of older adults, they have been largely absent from federal, state, and health system strategies for mitigating the spread of COVID-19. Future policies must include HCAs and their caregivers to optimize care for older adults.

Novel approaches to decrease inappropriate ambulatory antibiotic use.

Introduction: Inappropriate antibiotic use and antibiotic resistance are major public health threats. In the United States, most antibiotic use occurs in ambulatory care and 30% to 50% may be inappropriate. The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotics by 50% by 2020. Areas covered: This review summarizes the epidemiology of antibiotic use in ambulatory care and explores evidence-based, novel approaches for improving ambulatory antibiotic use. Expert opinion: We leveraged insights from behavioral science and social psychology to implement novel peer comparison - a form of audit-and-feedback - and accountable justification alert interventions that reduced inappropriate antibiotic prescribing to 5% or less. We and others have been successful in reducing inappropriate antibiotic prescribing with precommitment posters, communication training, combined patient/clinician education, and clinical decision support. Other commonly employed, but unsound approaches to reducing inappropriate antibiotic prescribing include point-of-care testing and delayed antibiotic prescriptions. These approaches are not durable (e.g. CRP testing), have not been proven in primary care (e.g. procalcitonin), or are conceptually flawed, such as using testing for non-antibiotic-appropriate diagnoses or using delayed antibiotic prescriptions. To decrease inappropriate ambulatory antibiotic use, clinicians, pharmacists, practices, and health systems need to collect antibiotic prescribing data, select concrete improvement targets, and implement evidence-based interventions such as peer comparison, accountable justification, precommitment, and communication training.

Sepsis in Older Adults.

Sepsis disproportionally affects older adults with more than 60% of sepsis diagnoses attributed to adults aged 65 years and older. Identifying, diagnosing, and treating sepsis in older individuals remain a challenge for clinicians, and few studies focus specifically on older adults with multiple medical comorbidities. Principles guiding management of sepsis for older adults are generally the same as in younger adults; however, unique considerations particularly pertinent to the care older adults include antimicrobial selection and dosing, delirium management, and goals of care discussions. Other factors, such as medical comorbidities, cognitive impairment, and functional status, impact outcomes more than age alone.

Fault Tree Analysis.

The purpose of this study was to use fault tree analysis to evaluate the adequacy of quality reporting programs in identifying root causes of postoperative bloodstream infection (BSI). A systematic review of the literature was used to construct a fault tree to evaluate 3 postoperative BSI reporting programs: National Surgical Quality Improvement Program (NSQIP), Centers for Medicare and Medicaid Services (CMS), and The Joint Commission (JC). The literature review revealed 699 eligible publications, 90 of which were used to create the fault tree containing 105 faults. A total of 14 identified faults are currently mandated for reporting to NSQIP, 5 to CMS, and 3 to JC; 2 or more programs require 4 identified faults. The fault tree identifies numerous contributing faults to postoperative BSI and reveals substantial variation in the requirements and ability of national quality data reporting programs to capture these potential faults. Efforts to prevent postoperative BSI require more comprehensive data collection to identify the root causes and develop high-reliability improvement strategies.

The Evolution of Living Kidney Donation and Transplantation in Older Adults.

Kidney transplantation is a good option for adults aged 65 and older with end-stage renal disease because it has been shown to reduce morbidity and mortality, improve quality of life, and is more cost-effective than other renal replacement options. However, older age has been a deterrent to access to the deceased donor waiting list, and individuals aged 65 and older have a lower probability of being referred to and listed for transplantation compared to younger adults. Because the deceased organ supply is limited, living donor kidney transplantation offers an effective alternative for older adults facing long waiting times for cadaveric organs. This article describes the evolution of living kidney donation and transplantation in older adults over 15 years using the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients database. Between 1997 and 2011, 28,034 kidney transplantations were performed in adults aged 65 and older. Living-donor and cadaveric kidney transplantation increased in older adults over the 15-year period. Offspring are the most common living donors in this age group, followed by unrelated donors (e.g., friends), whereas the most common donors in younger transplant recipients are spouses, siblings, and parents. The number of living kidney donors aged 65 and older is slowly increasing, although the total number of transplants in this age group remains low. The expansion of living-donor kidney transplantation in the aging population may offer a solution for organ shortage and thereby improve the quality of life of older adults. More research is needed to understand the older donor-recipient relationship and barriers to transplantation in this population.