Combining quality improvement and geriatrics training: the nursing home polypharmacy outcomes project.

To examine sustained effects of an educational intervention, the authors repeated a successful quality improvement (QI) project on medication safety and cost effectiveness. In October 2007 and August 2008, the facility leadership and geriatrics faculty identified all patients receiving nine or more medications (polypharmacy cohort) in a 170-bed teaching nursing home. They then taught Geriatric Medicine fellows (n = 12 in 2007, 11 in 2008) to (a) systematically collect medication data; (b) generate medication recommendations (stop, taper, or continue) based on expert criteria (Beers criteria) or drug-drug interaction programs; (c) discuss recommendations with patients' attending physicians; and (d) implement approved recommendations. Over the two projects, the polypharmacy cohorts demonstrated decreased potentially inappropriate medications (odds ratio [OR] = .78, 95% confidence interval [95% CI] [0.69, 0.88], p < .001), contraindicated medications (OR = .63, 95% CI [0.47, 0.85], p = .002) and medication costs (OR = .97, 95% CI [0.96, 0.99], p < .001). Findings suggest that programs planning educational QI projects for trainees may benefit from a multiyear approach to maximize clinical and educational benefits.

Describing Hawai'i's nursing home physicians: the results of a survey.

INTRODUCTION: Despite a growing need for physicians providing care to nursing home patients, the characteristics of physicians providing such care are not well described. METHODS: A survey was sent to adult primary care physicians in Hawai'i; respondents' demographic data were obtained. Associations between physician characteristics, level of nursing home experience, and island of practice were analyzed using chi square and multivariate logistic regression models. RESULTS: Of 806 physicians, 388 (48%) returned surveys. Controlling for years of experience and other demographic factors, having nursing home experience was associated with physician age (40 years and over compared with under 40 years; OR 3.5, 95% Confidence Interval (CI) 1.4-8.5), Family Medicine specialty (compared with Internal Medicine, General Practice or Other; OR 4.0, 95% CI 1.4-11.4), private practice type (compared with employed, other, and trainee physicians; OR 2.3, 95% CI 1. 1-4.6), and practice location (neighbor islands compared with Oahu, OR 4.5, 95% CI 1.1-17.8). Physicians practicing on the neighbor islands were more likely to be aged 40 years and older (OR 3.9, 95% CI 1.4-10.3), and white (ethnicity compared with all other ethnicities, OR 4.1, 95% CI 2.1-7.7). CONCLUSION: The association of higher physician age with both nursing home experience and neighbor island practice has important implications for the training of physicians to provide nursing home care in Hawai'i.

Knowledge and attitudes about geriatrics of medical students, internal medicine residents, and geriatric medicine fellows.

OBJECTIVES: To evaluate the attitudes and knowledge of medical students (MS1-3), internal medicine residents (postgraduate years 1 to 3 (PGY1-3)), and geriatric medicine fellows about elderly patients before implementation of a new geriatrics curriculum. DESIGN: Cross-sectional study. SETTING: An academic medical center. PARTICIPANTS: Two hundred eleven people participated: 54 MS1, 52 MS2, 50 MS3, 20 PGY1, 12 PGY2, 12 PGY3, and 11 geriatric medicine fellows. MEASUREMENTS: Each participant completed a questionnaire, including a 16-item geriatrics attitude scale, and a 23-item knowledge test (both revised versions of the University of California at Los Angeles (UCLA) Geriatrics Survey). Pearson correlation coefficients and t tests were used for statistical analyses. RESULTS: Both surveys demonstrated high internal consistency (alpha=0.70 and 0.71, respectively). Knowledge test scores increased with advancing level of training. MS1 and MS2 scored significantly lower and fellows scored significantly higher than others. PGY3 scored significantly higher than PGY1 on the knowledge test. All groups demonstrated positive attitudes toward geriatric patients (score>3.5). MS1 and fellows had significantly more favorable attitudes scores than more advanced students and residents. CONCLUSION: The results suggest that the UCLA Attitudes Scale and Knowledge Test can be used reliably to assess attitudes and knowledge level across all levels of medical education and training. The information from this study will be used to implement a more structured and comprehensive geriatrics curriculum across all trainee levels to improve attitudes and knowledge in the care of the geriatric patient.

Using standardized patients to assess the geriatrics medicine skills of medical students, internal medicine residents, and geriatrics medicine fellows.

PURPOSE: Medical schools and residency programs are placing additional emphasis on including clinical geriatrics competencies within their curricula. An eight-station, Geriatric Medicine Standardized Patient Examination (GSPX) was studied as a method to assess bedside geriatrics clinical skills over the continuum of medical education from medical school through residency and fellowship training. METHOD: The GSPX was administered to 39 medical students, 49 internal medicine residents, and 11 geriatrics medicine fellows in 2001-02. Reliability of standardized patient (SP) checklists and rating scales used to assess examinees' performance was measured by Cronbach's alpha. Validity was measured by surveying the examinees' assessment of fairness, individual case length, difficulty, and believability, and by faculty standard setting for each level of trainee. RESULTS: Reliability was high (alpha =.89). All levels of examinees found the SPs to be believable, station lengths to be adequate, and rated the GSPX as a fair assessment. Students rated the cases as more difficult. Previous experience with similar real patients increased significantly with level of training (Pearson's r =.48, p <.0001). Faculty set passing scores that increased from students to residents to fellows. However, GSPX scores decreased with level of training (r = -.25, p =.01). CONCLUSION: The GSPX is a reliable measure of geriatrics medicine skills with adequate face validity for examinees at all levels. However, GSPX scores did not increase with level of training, suggesting that a single form of the examination cannot be used across the continuum of training. Potential modifications to the GSPX that might provide more discrimination between levels of training are currently being explored.

Transfer of patients from acute to long-term care: influence of patient characteristics on waiting period.

Hawaii's number of nursing home beds per capita is much lower than the national average, making it difficult to transfer some hospitalized patients to long-term care facilities. We prospectively followed patients wait-listed for nursing home placement in two Honolulu hospitals and found several patient characteristics that impeded transfer. These results could be used to help with long-term care planning.

Reducing cost by reducing polypharmacy: the polypharmacy outcomes project.

OBJECTIVE: To examine the effect of intervention by geriatric medicine fellows and a geriatrician on medication cost among long term care residents with polypharmacy. DESIGN: Interventional study. SETTING: A single hospital-affiliated long term care facility. PARTICIPANTS: Long term care residents with polypharmacy, defined as being on 9 or more medications. INTERVENTION: Medication lists of all nursing home residents were reviewed in October 2007 by geriatric medicine fellows and a faculty geriatrician using the 2003 Beers Criteria and the Epocrates online drug-drug interaction program. Recommendations for each resident were prepared and discussed directly with their primary physicians, who made the final decisions regarding medication discontinuation or taper. MEASUREMENTS: Mean monthly costs (derived from current retail prices) for overall as well as scheduled and pro re nata (PRN) medications were compared before and after the intervention. Estimated reduction in nursing administration time and cost were calculated based on published literature on medication administration time and nursing labor costs. RESULTS: Seventy-four (46.3%) of 160 residents were on 9 or more medications. Four residents died or were discharged before the intervention, leaving a final sample of 70 residents for the intervention. After the intervention, mean monthly medication costs per resident significantly decreased; overall medications, from $874.27 to $843.56 (P < .0001); scheduled medications, from $814.05 to $801.14 (P= .007); PRN medications, from $60.22 to $42.43 (P < .0001). Gastrointestinal medications demonstrated the highest cost savings of all medication categories (eg, promethazine and proton pump inhibitors), followed by central nervous system-active medications (including benzodiazepines and fluoxetine), then analgesics and diabetes medications. CONCLUSION: This polypharmacy reduction intervention by physicians used readily available tools, demonstrated a significant decrease in medication-related costs, and provided training in the core competencies of practice-based learning and improvement and systems-based practice to geriatric medicine fellows in long term care.

Factors associated with physician decision-making in starting tube feeding.

BACKGROUND: Because tube-feeding decisions are sometimes difficult, we examined physician, institutional, and patient factors associated with these decisions. METHODS: Primary care physicians (n = 388) likely to manage nursing home patients in Hawaii were surveyed. Respondents indicated the factors of great importance in tube feeding decisions based on a vignette of a poststroke patient failing to thrive and family disagreement with advance directives. chi(2) and multiple logistic regression analyses were used to examine associations between physician demographics and factors of importance to physicians and their decisions based on the vignette. RESULTS: Starting tube feeding (chosen by 31% of respondents) was associated with internal medicine specialty (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4-4.6), and placing great importance on family preference (OR 5.4, 95% CI 3.0-9.8) and liability (OR 2.5, 95% CI 1.3-4.8). After 3 months without improvement, 58% chose to withdraw tube feeding. Continuing tube feeding was associated with placing great importance on family wishes (OR 3.0, 95% CI 1.8-5.1) and liability (OR 1.7, 95% CI 1.0-2.9). Placing great importance on the living will was associated with decreased likelihoods of starting (OR 0.1, 95% CI 0.04-0.3) and continuing (OR 0.1, 95% CI 0.04-0.3) tube feeding. CONCLUSIONS: The decision to start or withhold tube feeding is associated with the individual physician's perception of the importance of patient wishes versus family wishes and liability concerns. Physician awareness of the influence of these factors on medical decisions may improve the decision-making process.