Barriers to delirium screening and management during hospital admission: a qualitative analysis of inpatient nursing perspectives.

BACKGROUND: Delirium in hospitalized patients is a major public health issue, yet delirium is often unrecognized and missed during inpatient admission. The objective of this study was to identify barriers to delirium screening, identification, and management from a nursing perspective on inpatient, acute care units. METHODS: This was a pre-implementation, diagnostic evaluation study to determine current practice patterns and potential barriers to optimizing delirium care at a major university hospital. A qualitative approach was used, which included focus groups of inpatient nurses working on major medical and surgical acute care units. Focus groups were conducted until signs of thematic saturation were present, and data were analyzed via inductive thematic analysis, without predetermined theories or structures. A consensus approach was utilized for transcript coding, and final themes were generated after multiple reviews of initial themes against transcript datasets. RESULTS: Focus group sessions (n = 3) were held with 18 nurses across two major inpatient units. Nurses reported several barriers to successful delirium screening and management. Specific challenges included difficulty with using delirium screening tools, an organizational culture not conducive to delirium prevention, and competing clinical priorities. Proposed solutions were also discussed, including decision-support systems with automated pager alerts and associated delirium order sets, which may help improve delirium care coordination and standardization. CONCLUSION: At a major university hospital, nurses affirm the difficulty experienced with delirium screening and identification, particularly due to screening tool challenges, cultural barriers, and clinical workload. These impediments may serve as targets for a future implementation trial to improve delirium screening and management.

Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults: A Mixed Methods Study.

PURPOSE: Unlike in many community-based settings, benzodiazepine (BZD) prescribing to older veterans has decreased. We sought to identify health care system strategies associated with greater facility-level reductions in BZD prescribing to older adults. METHODS: We completed an explanatory sequential mixed methods study of health care facilities in the Veterans Health Administration (N = 140). Among veterans aged ≥75 years receiving long-term BZD treatment, we stratified facilities into relatively high and low performance on the basis of the reduction in average daily dose of prescribed BZD from October 1, 2015 to June 30, 2017. We then interviewed key facility informants (n = 21) who led local BZD reduction efforts (champions), representing 11 high-performing and 6 low-performing facilities. RESULTS: Across all facilities, the age-adjusted facility-level average daily dose in October 2015 began at 1.34 lorazepam-equivalent mg/d (SD 0.17); the average rate of decrease was -0.27 mg/d (SD 0.09) per year. All facilities interviewed, regardless of performance, used passive strategies primarily consisting of education regarding appropriate prescribing, alternatives, and identifying potential patients for discontinuation. In contrast, champions at high-performing facilities described leveraging ≥1 active strategies that included individualized recommendations, administrative barriers to prescribing, and performance measures to incentivize clinicians. CONCLUSIONS: Initiatives to reduce BZD prescribing to older adults that are primarily limited to passive strategies, such as education and patient identification, might have limited success. Clinicians might benefit from additional recommendations, support, and incentives to modify prescribing practices.

Prescription characteristics associated with fall-related injury risk among older adults prescribed benzodiazepines: a cohort study.

BACKGROUND: Benzodiazepines (BZD) are widely prescribed to older adults despite their association with increased fall injury. Our aim is to better characterize risk-elevating factors among those prescribed BZD. METHODS: A retrospective cohort study using a 20% sample of Medicare beneficiaries with Part D prescription drug coverage. Patients with a BZD prescription ("index") between 1 April 2016 and 31 December 2017 contributed to incident (n=379,273) and continuing (n=509,634) cohorts based on prescriptions during a 6-month pre-index baseline. Exposures were index BZD average daily dose and days prescribed; baseline BZD medication possession ratio (MPR) (for the continuing cohort); and co-prescribed central nervous system-active medications. Outcome was a treated fall-related injury within 30 days post-index BZD, examined using Cox proportional hazards adjusting for demographic and clinical covariates and the dose prescribed. RESULTS: Among incident and continuing cohorts, 0.9% and 0.7% experienced fall injury within 30 days of index. In both cohorts, injury risk was elevated immediately post-index among those prescribed the lowest quantity: e.g., for <14-day fill (ref: 14-30 days) in the incident cohort, risk was 37% higher the 10 days post-fill (adjusted hazard ratio [HR] 1.37 [95% confidence interval [CI] 1.19-1.59]). Risk was elevated immediately post-index for continuing users with low baseline BZD exposure (e.g., for MPR <0.5 [ref: MPR 0.5-1], HR during days 1-10 was 1.23 [CI 1.08-1.39]). Concurrent antipsychotics and opioids were associated with elevated injury risk in both cohorts (e.g., incident HRs 1.21 [CI 1.03-1.40] and 1.22 [CI 1.07-1.40], respectively; continuing HRs 1.23 [1.10-1.37] and 1.21 [1.11-1.33]). CONCLUSIONS: Low baseline BZD exposure and a small index prescription were associated with higher fall injury risk immediately after a BZD fill. Concurrent exposure to antipsychotics and opioids were associated with elevated short-term risk for both incident and continuing cohorts.

Adding a New Medication Versus Maximizing Dose to Intensify Hypertension Treatment in Older Adults : A Retrospective Observational Study.

BACKGROUND: There are 2 approaches to intensifying antihypertensive treatment when target blood pressure is not reached, adding a new medication and maximizing dose. Which strategy is better is unknown. OBJECTIVE: To assess the frequency of intensification by adding a new medication versus maximizing dose, as well as the association of each method with intensification sustainability and follow-up systolic blood pressure (SBP). DESIGN: Large-scale, population-based, retrospective cohort study. Observational data were used to emulate a target trial with 2 groups, new medication and maximizing dose, who underwent intensification of their drug regimen. SETTING: Veterans Health Administration (2011 to 2013). PATIENTS: Veterans aged 65 years or older with hypertension, an SBP of 130 mm Hg or higher, and at least 1 antihypertensive medication at less than the maximum dose. MEASUREMENTS: The following 2 intensification approaches were emulated: adding a new medication, defined as a total dose increase with new medication, and maximizing dose, defined as a total dose increase without new medication. Inverse probability weighting was used to assess the observational effectiveness of the intensification approach on sustainability of intensified treatment and follow-up SBP at 3 and 12 months. RESULTS: Among 178 562 patients, 45 575 (25.5%) had intensification by adding a new medication and 132 987 (74.5%) by maximizing dose. Compared with maximizing dose, adding a new medication was associated with less intensification sustainability (average treatment effect, -15.2% [95% CI, -15.7% to -14.6%] at 3 months and -15.1% [CI, -15.6% to -14.5%] at 12 months) but a slightly larger reduction in mean SBP (-0.8 mm Hg [CI, -1.2 to -0.4 mm Hg] at 3 months and -1.1 mm Hg [CI, -1.6 to -0.6 mm Hg] at 12 months). LIMITATION: Observational data; largely male population. CONCLUSION: Adding a new antihypertensive medication was less frequent and was associated with less intensification sustainability but slightly larger reductions in SBP. Trials would provide the most definitive support for our findings. PRIMARY FUNDING SOURCE: National Institute on Aging and Veterans Health Administration.

Benzodiazepine Prescribing from VA and Medicare to Dually Enrolled Older Veterans: A Retrospective Cohort Study.

BACKGROUND: There has been a reduction in BZD prescribing in the Veterans Affairs (VA) health care system since 2013. It is unknown whether the decline in VA-dispensed BZDs has been offset by Medicare Part D prescriptions. OBJECTIVES: To examine (1) whether, accounting for Part D, declines in BZD prescribing to older Veterans remain; (2) patient characteristics associated with obtaining BZDs outside VA and facility variation in BZD source (VA only, VA and Part D, Part D only). DESIGN: Retrospective cohort study with mixed effects multinomial logistic model examining characteristics associated with BZD source. PATIENTS: A total of 1,746,278 Veterans aged ≥65 enrolled in VA and Part D, 2013-2017. MAIN MEASURES: BZD prescription prevalence and source. KEY RESULTS: From January 2013 to June 2017, the quarterly prevalence of older Veterans with Part D filling BZD prescriptions through the VA declined from 5.2 to 3.1% (p<0.001) or, accounting for Part D, from 10.0 to 7.7% (p<0.001). Among those prescribed BZDs between July 2016 and June 2017, 37.0%, 10.2%, and 52.8% received prescriptions from VA only, both VA and Part D, or Part D only, respectively. Older age was associated with higher odds of obtaining BZDs through Part D (e.g., compared to those 65-74, Veterans ≥85 had adjusted odds ratio [AOR] for Part D vs. VA only of 1.8 [95% highest posterior density interval (HPDI), 1.69, 1.86]). Veterans with substance use disorders accounted for few BZD prescriptions from any source but were associated with higher odds of prescriptions through Part D (e.g., alcohol use disorder AOR for Part D vs. VA alone: 1.9 [95% HPDI, 1.63, 2.11]) CONCLUSIONS: The decline in BZD use by older Veterans with Part D coverage remained after accounting for Part D, but the majority of BZD prescriptions came from Medicare. Further reducing BZD prescribing to older Veterans should consider prescriptions from community sources.

Comprehensive review of ICD-9 code accuracies to measure multimorbidity in administrative data.

BACKGROUND: Quantifying the burden of multimorbidity for healthcare research using administrative data has been constrained. Existing measures incompletely capture chronic conditions of relevance and are narrowly focused on risk-adjustment for mortality, healthcare cost or utilization. Moreover, the measures have not undergone a rigorous review for how accurately the components, specifically the International Classification of Diseases, Ninth Revision (ICD-9) codes, represent the chronic conditions that comprise the measures. We performed a comprehensive, structured literature review of research studies on the accuracy of ICD-9 codes validated using external sources across an inventory of 81 chronic conditions. The conditions as a weighted measure set have previously been demonstrated to impact not only mortality but also physical and mental health-related quality of life. METHODS: For each of 81 conditions we performed a structured literature search with the goal to identify 1) studies that externally validate ICD-9 codes mapped to each chronic condition against an external source of data, and 2) the accuracy of ICD-9 codes reported in the identified validation studies. The primary measure of accuracy was the positive predictive value (PPV). We also reported negative predictive value (NPV), sensitivity, specificity, and kappa statistics when available. We searched PubMed and Google Scholar for studies published before June 2019. RESULTS: We identified studies with validation statistics of ICD-9 codes for 51 (64%) of 81 conditions. Most of the studies (47/51 or 92%) used medical chart review as the external reference standard. Of the validated using medical chart review, the median (range) of mean PPVs was 85% (39-100%) and NPVs was 91% (41-100%). Most conditions had at least one validation study reporting PPV ≥70%. CONCLUSIONS: To help facilitate the use of patient-centered measures of multimorbidity in administrative data, this review provides the accuracy of ICD-9 codes for chronic conditions that impact a universally valued patient-centered outcome: health-related quality of life. These findings will assist health services studies that measure chronic disease burden and risk-adjust for comorbidity and multimorbidity using patient-centered outcomes in administrative data.

Unrealistic Postsurgical Expectation of Independence Predicts Complex Hospital Discharge.

BACKGROUND: Careful discharge planning for older surgical patients can reduce length of stay, readmission, and cost. We hypothesized that patients who overestimate their self-care ability before surgery are more likely to have complex postoperative discharge planning. MATERIALS AND METHODS: The Vulnerable Elders Surgical Pathways and Outcomes Assessment is a brief preoperative assessment that can identify older (age ≥70) patients with multidimensional geriatric risk, defined by all three of the following: (1) physical or cognitive impairment, (2) living alone, and (3) lack of handicap-accessible home. The Vulnerable Elders Surgical Pathways and Outcomes Assessment also asks a novel postoperative self-care ability question, whether patient can independently provide self-care for several hours after discharge. Classifying patients into four groups based on multidimensional geriatric risk (full versus none or partial) and the self-care ability question (yes or no), we hypothesized those with unrealistic postsurgical expectation of independence (UPSI) (both fully at risk and "yes" to self-care ability question) would be at the increased risk for complex discharge planning. Complex discharge planning was defined as prolonged stay because of nonmedical reasons or multiple changes in discharge plans. RESULTS: In 382 hospitalizations of ≥2 d, 366 had a nonmissing answer to the self-care question; of those 5% had UPSI and 6.3% needed complex discharge planning. The UPSI group was independently associated with greater risk of complex discharge planning compared with the normal group (odds ratio = 4.3 [95% confidence interval, 1.1-16.1]). CONCLUSIONS: Complex discharges were rare, but predictable by preoperative geriatric screening. Patients with UPSI should be targeted for postoperative care planning in advance of surgery.

Longitudinal Assessment of Multidrug-Resistant Organisms in Newly Admitted Nursing Facility Patients: Implications for an Evolving Population.

Background: The spread of multidrug-resistant organisms (MDROs) is a global concern, and much about transmission in healthcare systems remains unknown. To reduce hospital stays, nursing facilities (NFs) have increasingly assumed care of post-acute populations. We estimate the prevalence of MDRO colonization in NF patients on enrollment and discharge to community settings, risk factors for colonization, and rates of acquiring MDROs during the stay. Methods: We conducted a prospective, longitudinal cohort study of newly admitted patients in 6 NFs in southeast Michigan using active microbial surveillance of multiple anatomic sites sampled at enrollment, days 14 and 30, and monthly thereafter for up to 6 months. Results: We enrolled 651 patients and collected 7526 samples over 1629 visits, with an average of 29 days of follow-up per participant. Nearly all participants were admitted for post-acute care (95%). More than half (56.8%) were colonized with MDROs at enrollment: methicillin-resistant Staphylococcus aureus (MRSA), 16.1%; vancomycin-resistant enterococci (VRE), 33.2%; and resistant gram-negative bacilli (R-GNB), 32.0%. Risk factors for colonization at enrollment included prolonged hospitalization (>14 days), functional disability, antibiotic use, or device use. Rates per 1000 patient-days of acquiring a new MDRO were MRSA, 3.4; VRE, 8.2; and R-GNB, 13.6. MDRO colonization at discharge was similar to that at enrollment (56.4%): MRSA, 18.4%; VRE, 30.3%; and R-GNB, 33.6%. Conclusions: Short-stay NF patients exhibit a high prevalence of MDROs near the time of admission, as well as at discharge, and may serve as a reservoir for spread in other healthcare settings. Future interventions to reduce MDROs should specifically target this population.

Longitudinal functional recovery after geriatric cardiac surgery.

BACKGROUND: Impaired functional and cognitive status is an important outcome for older adults undergoing major cardiac surgery. We conducted this pilot study to gauge feasibility of assessing these outcomes longitudinally, from preoperatively up to two time points postoperatively to assess for recovery. METHODS: We interviewed patients aged ≥ 65 y preoperatively and repeated functional and cognitive assessments at 4-6 wk and 4-6 mo postoperatively. Simple unadjusted linear regression was used to test whether baseline measures changed at each follow-up time point. Then we used a longitudinal model to predict postoperative recovery overall, adjusting for comorbidity. RESULTS: A total of 62 patients (age 74.7 ± 5.9) underwent scheduled cardiac surgery. Preoperative activities of daily living (ADL) impairment was associated with poorer functional recovery at 4-6 wk postoperatively with each baseline ADL impairment conferring recovery of 0.5 fewer ADLs (P < 0.05). By 4-6 mo, we could no longer detect a difference in recovery. Preoperative cognition and physical activity were not associated with postoperative changes in these domains. CONCLUSIONS: A preoperative and postoperative evaluation of function and cognition was integrated into the surgical care of older patients. Preoperative impairments in ADLs may be a means to identify patients who might benefit from careful postoperative planning, especially in terms of assistance with self-care during the first 4-6 wk after cardiac surgery.

Analytic morphomics corresponds to functional status in older patients.

BACKGROUND: Older patients account for nearly half of the United States surgical volume, and age alone is insufficient to predict surgical fitness. Various metrics exist for risk stratification, but little work has been done to describe the association between measures. We aimed to determine whether analytic morphomics, a novel objective risk assessment tool, correlates with functional measures currently recommended in the preoperative evaluation of older patients. MATERIALS AND METHODS: We retrospectively identified 184 elective general surgery patients aged >70 y with both a preoperative computed tomography scan and Vulnerable Elderly Surgical Pathways and outcomes Assessment within 90 d of surgery. We used analytic morphomics to calculate trunk muscle size (or total psoas area [TPA]) and univariate logistic regression to assess the relationship between TPA and domains of geriatric function mobility, basic and instrumental activities of daily living (ADLs), and cognitive ability. RESULTS: Greater TPA was inversely correlated with impaired mobility (odds ratio [OR] = 0.46, 95% confidence interval [CI] 0.25-0.85, P = 0.013). Greater TPA was associated with decreased odds of deficit in any basic ADLs (OR = 0.36 per standard deviation unit increase in TPA, 95% CI 0.15-0.87, P <0.03) and any instrumental ADLs (OR = 0.53, 95% CI 0.34-0.81; P <0.005). Finally, patients with larger TPA were less likely to have cognitive difficulty assessed by Mini-Cog scale (OR = 0.55, 95% CI 0.35-0.86, P <0.01). Controlling for age did not change results. CONCLUSIONS: Older surgical candidates with greater trunk muscle size, or greater TPA, are less likely to have physical impairment, cognitive difficulty, or decreased ability to perform daily self-care. Further research linking these assessments to clinical outcomes is needed.

Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

OBJECTIVE: To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs). DATA SOURCES AND STUDY SETTING: Secondary data from Medicare were used. STUDY DESIGN: Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities). DATA COLLECTION: Not applicable. PRINCIPAL FINDINGS: We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001). CONCLUSIONS: HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

Post-acute sequelae of SARS-CoV-2 (PASC) in nursing home residents: A retrospective cohort study.

BACKGROUND: Post-acute sequelae of SARS-CoV-2 (PASC) describes a syndrome of physical and cognitive decline that persists after acute symptoms of infection resolve. Few studies have explored PASC among nursing home (NH) residents. METHODS: A retrospective cohort study was conducted at two NHs in Michigan. COVID-positive patients were identified from March 21, 2020 to October 26, 2021. The comparison group were patients who lived at the same NH but who were never infected during the study period. Minimum Data Set was used to examine trajectories of functional dependence (Activity of Daily Living [ADL] composite score) and cognitive function (Brief Interview for Mental Status [BIMS]). Linear mixed-effects models were constructed to estimate short-term change in function and cognition immediately following diagnosis and over time for an additional 12 months, compared to pre-COVID and non-COVID trajectories and adjusting for sex, age, and dementia status. RESULTS: We identified 171 residents (90 COVID-19 positive, 81 non-COVID) with 719 observations for our analyses. Cohort characteristics included: 108 (63%) ≥ 80 yrs.; 121 (71%) female; 160 (94%) non-Hispanic white; median of 3 comorbidities (IQR 2-4), with no significant differences in characteristics between groups. COVID-19 infection affected the trajectory of ADL recovery for the first 9 months following infection, characterized by an immediate post-infection decrease in functional status post-infection (-0.60 points, p = 0.002) followed by improvement toward the expected functional trajectory sans infection (0.04 points per month following infection, p = 0.271). CONCLUSIONS: NH residents experienced a significant functional decline that persisted for 9 months following acute infection. Further research is needed to determine whether increased rehabilitation services after COVID-19 may help mitigate this decline.

Validation of a Rule-Based ICD-10-CM Algorithm to Detect Fall Injuries in Medicare Data.

BACKGROUND: Diagnosis-code-based algorithms to identify fall injuries in Medicare data are useful for ascertaining outcomes in interventional and observational studies. However, these algorithms have not been validated against a fully external reference standard, in ICD-10-CM, or in Medicare Advantage (MA) data. METHODS: We linked self-reported fall injuries leading to medical attention (FIMA) from the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial (reference standard) to Medicare fee-for-service (FFS) and MA data from 2015-19. We measured the area under the receiver operating characteristic curve (AUC) based on sensitivity and specificity of a diagnosis-code-based algorithm against the reference standard for presence or absence of ≥1 FIMA within a specified window of dates, varying the window size to obtain points on the curve. We stratified results by source (FFS vs MA), trial arm (intervention vs control), and STRIDE's 10 participating health care systems. RESULTS: Both reference standard data and Medicare data were available for 4 941 (of 5 451) participants. The reference standard and algorithm identified 2 054 and 2 067 FIMA, respectively. The algorithm had 45% sensitivity (95% confidence interval [CI]: 43%-47%) and 99% specificity (95% CI: 99%-99%) to identify reference standard FIMA within the same calendar month. The AUC was 0.79 (95% CI: 0.78-0.81) and was similar by FFS or MA data source and by trial arm but showed variation among STRIDE health care systems (AUC range by health care system, 0.71 to 0.84). CONCLUSIONS: An ICD-10-CM algorithm to identify fall injuries demonstrated acceptable performance against an external reference standard, in both MA and FFS data.

Improved accuracy and efficiency of primary care fall risk screening of older adults using a machine learning approach.

BACKGROUND: While many falls are preventable, they remain a leading cause of injury and death in older adults. Primary care clinics largely rely on screening questionnaires to identify people at risk of falls. Limitations of standard fall risk screening questionnaires include suboptimal accuracy, missing data, and non-standard formats, which hinder early identification of risk and prevention of fall injury. We used machine learning methods to develop and evaluate electronic health record (EHR)-based tools to identify older adults at risk of fall-related injuries in a primary care population and compared this approach to standard fall screening questionnaires. METHODS: Using patient-level clinical data from an integrated healthcare system consisting of 16-member institutions, we conducted a case-control study to develop and evaluate prediction models for fall-related injuries in older adults. Questionnaire-derived prediction with three questions from a commonly used fall risk screening tool was evaluated. We then developed four temporal machine learning models using routinely available longitudinal EHR data to predict the future risk of fall injury. We also developed a fall injury-prevention clinical decision support (CDS) implementation prototype to link preventative interventions to patient-specific fall injury risk factors. RESULTS: Questionnaire-based risk screening achieved area under the receiver operating characteristic curve (AUC) up to 0.59 with 23% to 33% similarity for each pair of three fall injury screening questions. EHR-based machine learning risk screening showed significantly improved performance (best AUROC = 0.76), with similar prediction performance between 6-month and one-year prediction models. CONCLUSIONS: The current method of questionnaire-based fall risk screening of older adults is suboptimal with redundant items, inadequate precision, and no linkage to prevention. A machine learning fall injury prediction method can accurately predict risk with superior sensitivity while freeing up clinical time for initiating personalized fall prevention interventions. The developed algorithm and data science pipeline can impact routine primary care fall prevention practice.

Geriatric Education on Telehealth (GET) Access: A medical student volunteer program to increase access to geriatric telehealth services at the onset of COVID-19.

The coronavirus disease 2019 pandemic placed an unprecedented demand on health systems to rapidly shift ambulatory in-person care to virtual care. Geriatric patients face more challenges with video visit access compared to younger patients due to discomfort with technology and less access to devices and internet. Medical students at the University of Michigan created an initiative to improve access to and comfort with video visits for geriatric patients. The program's goals were to (a) explore options for the delivery of personalized training to older adults, (b) create materials for volunteers to successfully navigate conversations with patients and caregivers, (c) provide patients one-to-one remote guidance while identifying and overcoming barriers-with practice sessions to increase comfort, (d) share with the larger health system, and (e) ensure program sustainability. Over a 10-week evaluation period, providers whose patients worked with our geriatric education on telehealth access volunteers had a video visit rate of 43% compared to 19.2% prior to participation in the program (adjusted odds ratio = 3.38, 95% confidence interval = 2.49, 4.59), ultimately providing a platform for geriatric patients to foster stronger connections with their providers, while increasing Michigan Medicine's overall proportion of video telehealth visits.

Interprofessional geriatric and palliative care intervention associated with fewer hospital days.

BACKGROUND: With increasing complexity of our aging inpatient population, we implemented an interprofessional geriatric and palliative care intervention on a hospitalist service. This study aimed to measure the intervention's impact on length of stay (LOS), 30-day readmission, and the daily intensity of inpatient services utilization. METHODS: Using a nonrandomized controlled intervention at a 1000-bed U.S. academic quaternary medical center, we studied 13,941 individuals admitted to a general medicine hospitalist service (of which 5644 were age > =65 years); 1483 were on intervention teams (576 age > =65 years), 5413 concurrent controls, and 7045 historical controls. On 2 of 11 hospitalist teams, a geriatrician, palliative care physician and social worker attended multidisciplinary discharge rounds twice weekly, to recommend inpatient geriatric or palliative care consult (GPCC), postacute nursing or home care, versus postdischarge outpatient consultation. We measured the difference in improvement over time between intervention and control team patients for the following: (1) LOS adjusted for case-mix index, (2) 30-day readmissions, and (3) intensity of hospital service utilization (mean services provided per patient per day). RESULTS: Adjusted LOS (in hospital days) was decreased by 0.36 days (p = 0.039) for the 1483 patients in the intervention teams, with greater LOS reduction of 0.55 days per admission (p = 0.022) on average among the subset of 576 older patient admissions. Readmissions were unchanged (-1.17%, p = 0.48 for all patients; 1.91%, p = 0.46 for older patients). However, the daily relative value unit (RVU) utilization was modestly increased for both the overall and older subgroup, 0.35 RVUs (p = 0.041) and 0.74 RVUs (p < 0.001) per patient-day on average across the intervention teams, respectively. CONCLUSION: An interprofessional intervention of geriatric and palliative care consultation in collaboration with a hospitalist service may reduce LOS, especially for geriatric patients, without an increase in readmissions. This model may have broader implications for hospital care and should be further studied.

Evaluating alternative methods of comparing antihypertensive treatment intensity.

OBJECTIVES: To change blood pressure treatment, clinicians can modify medication count or dose. However, existing studies have measured count modification, which may miss clinically important dose change in the absence of count change. This research demonstrates how dose modification captures more information about management than medication count alone. STUDY DESIGN: Retrospective cohort study. METHODS: We included patients 65 years and older with established primary care at the Veterans Health Administration (July 2011-June 2013). We captured medication count and standardized dose change over 90 to 120 days using a validated pharmacy fill algorithm. We determined frequency of dose change without count change (and vice versa), no change in either, change in same direction ("concordant"), and change in opposite direction ("discordant"). We compared change according to systolic blood pressure (SBP) and compared concordance using a minimum threshold definition of dose change of at least 50% (instead of any change) of baseline dose modification. RESULTS: Among 440,801 patients, 64.2% had dose change; 22.0%, count change; 35.6%, no change in either; 42.4%, dose change without count modification; and 0.2%, count change without dose modification. Discordance occurred in 2.1% of observations. Using the minimum threshold definition of change, 68.7% had no change in either dose or count. Treatment was more frequently changed at SBP greater than 140 mm Hg. CONCLUSIONS: Measuring change in antihypertensive treatment using medication count frequently missed an isolated dose change in treatment modification and less often misclassified regimen modifications where there was no modification in total dose. In future research, measuring dose modification using our new algorithm would capture change in hypertension treatment intensity more precisely than current methods.