Effect of canakinumab on frailty: A post hoc analysis of the CANTOS trial.

Although inflammation is strongly associated with frailty, whether medications that lower inflammation decrease frailty is unclear and randomized trial evidence is scant. We sought to test whether canakinumab, a therapeutic monoclonal antibody that inhibits IL-1ß and reduces C-reactive protein (CRP), can lower frailty risk. This was a post hoc analysis of the Canakinumab ANti-inflammatory Thrombosis Outcome Study (CANTOS), a randomized double-blind placebo-controlled trial of 10,061 stable postmyocardial infarction patients randomized to subcutaneous canakinumab once every 3 months. Incident frailty was measured using a 34-item cumulative-deficit Frailty Index (FI). Time-to-event analysis using intent to treat. A total of 9942 CANTOS participants had data to calculate a baseline FI. Median age was 61 (IQR 54-68); 74% were male, 12% Asian, 3% Black, 80% White, and 16% Hispanic/Latino. At baseline, mean FI score was 0.12 and 13% were frail using a cutoff of 0.2. Over 5 years, 1080 participants (12.5%) became frail and mean FI scores increased to 0.14. There was no effect on frailty incidence according to randomization to any canakinumab dose versus placebo over time, HR 1.03 (0.91-1.17), p = 0.63. Results were similar using phenotypic frailty. Additionally, the primary findings of CANTOS in terms of canakinumab-associated cardiovascular event reduction were unchanged in analyses stratified by baseline frailty. In conclusion, among stable adult patients with atherosclerosis, random allocation to interleukin-1b inhibition with canakinumab versus placebo did not lower risk of incident frailty over 5 years. More randomized data are needed to understand the role of targeted anti-inflammatory medications for frailty prevention in older adults.

Improvise, Adapt & Overcome: Successful Surgery-Sparing Prosthetic Hip Infection Antibiotic Suppression During COVID-19 Crisis.

CASE: A 79-year-old active male presented during the first COVID-19 pandemic surgery moratorium with late Staphylococcus lugdunensis periprosthetic total hip arthroplasty infection. Due to the unprecedented circumstances, novel treatment of IV and oral antibiotic suppression was trialed without preceding surgical intervention. At latest follow-up, the patient has two-year revision-free survival with normalization of inflammatory markers and MRI findings, and resolution of clinical symptoms. CONCLUSION: We report a novel surgery-sparing treatment for periprosthetic hip infection. Judicious caution should be used in the application of similar therapies, as host and organism characteristics likely contributed substantially to the success of this case.

Derivation and Validation of a Predictive Algorithm for Long-Term Care Admission or Death.

OBJECTIVES: Older veterans prefer to remain in their homes and communities as long as possible. Although targeted delivery of home- and community-based services for veterans might delay long-term care placement, often, access to these services is inconsistently organized or delayed. To aid in early recognition of veterans at high risk for long-term care placement or death, we developed and validated a predictive algorithm, "Choose Home." DESIGN: A retrospective observational cohort analysis was used. SETTING AND PARTICIPANTS: Two cohorts of Veterans Health Administration (VHA; a large integrated health care system) users were assembled: Derivation (4.6 million) and Confirmation (4.7 million). The Derivation Cohort included Veterans Administration users from fiscal year 2013; the Confirmation Cohort included Veterans Administration users from fiscal year 2014. METHODS: A total of 148 predictor variables, including demographics, comorbidities, and utilizations were selected using logistic regression to predict placement in a long-term care facility for >90 days or death within 2 years. RESULTS: Veterans were predominantly male [92.8% (Derivation), 92.5% (Confirmation)] and older [61.7±15.5 (Derivation), 61.5±15.6 years (Confirmation)], with a high prevalence of comorbid conditions. Between the Derivation and Confirmation Cohorts, the areas under the receiver operating characteristic curves were found to be 0.80 [95% confidence interval (CI) 0.799, 0.802] and 0.80 (95% CI 0.800, 0.802), respectively, indicating good discrimination for determining at-risk veterans. CONCLUSIONS AND IMPLICATIONS: We created a predictive algorithm that identifies veterans at highest risk for long-term institutionalization or death. This algorithm provides clinicians with information that can proactively inform clinical decision making and care coordination. This study provides the groundwork for future investigations on how home- and community-based services can target older adults at highest risk to extend time in their communities.

Shaping the Rhode Island Duals Demonstration: The Power of Partnerships between Advocates and Geriatrics Experts.

This paper describes a unique collaboration between consumer health care advocates, experts in geriatrics, a state, and a health plan to improve care for adults with both Medicare and Medicaid. Ineffective care coordination between the Medicare and Medicaid programs has led to poor care and high costs. As part of the Affordable Care Act (ACA), CMS initiated state demonstrations to align financing and care delivery. In 2016, Rhode Island launched an integrated care model. Geriatrics experts teamed up with an aging services advocate to work on the Rhode Island project. The team's objective was to bring a geriatrics lens to policy development and clinical care. The team made critical recommendations to the state and CMS during the planning stage, and geriatrics experts presented trainings to health plan care providers. The project demonstrated the potential for geriatrics experts partnering with consumer advocates to influence policy development and implementation.

Effects of Medicare Medical Reviews on Ambiguous Short-Stay Hospital Admissions.

OBJECTIVE: To examine the effects of Medicare's Medical Review (MR) program on short-stay inpatient hospitalization. DATA SOURCES/STUDY SETTING: One Hundred percent of Medicare Part A and Part B claims and the Master Beneficiary Summary File (2007-2010). STUDY DESIGN: Retrospective observational study using a difference-in-differences approach. We examined six primary intake diagnoses, we believed likely to be targeted by MR. We stratified by hospital profit structure, bed size, system membership, and inpatient admission rate to test for differential effects. The comparison group was hospital visits occurring in those MACs that had yet to implement, as well as those that did not implement during the period of interest. DATA COLLECTION: None. PRINCIPAL FINDINGS: Medical Review significantly reduced the likelihood of inpatient admission for patients with an intake diagnosis of "Non-Specific Chest Pain" by 1.29 percentage points (p < .001). This effect was stronger in larger hospitals (-2.03, p < .001), nonsystem hospitals (-2.54, p < .001), and those with a lower inpatient rate (-1.86, p < .001). CONCLUSIONS: Short inpatient hospitalizations were emphasized by MR, and our results show that MR modestly reduced their prevalence among certain patients and certain hospitals. Future work should examine whether this resulted in adverse patient outcomes.

The relationship between different settings of medical service and incident frailty.

BACKGROUND: Some studies have reported a potential association between usual source of health care and disability, but no one has explored the association with frailty, a state of early and potential reversible disability. We therefore aimed to explore the association between older persons' self-reported usual source of health care at baseline and the onset of frailty. METHODS: Information regarding usual source of health care was captured through self-report and categorized as 1) private doctor's office, 2) public clinic, 3) Health Maintenance Organization (HMO), or 4) hospital clinic/emergency department (ED). Frailty was defined using the Study of Osteoporotic Fracture (SOF) index as the presence of at least two of the following criteria: (i) weight loss ≥5% between baseline and any subsequent follow-up visit; (ii) inability to do five chair stands; and (iii) low energy level according to the SOF definition. Multivariable Cox's regression analyses, calculating hazard ratios (HRs) with 95% confidence intervals (CIs), were undertaken. RESULTS: Of the 4292 participants (mean age: 61.3), 58.7% were female. During the 8-year follow-up, 348 subjects (8.1% of the baseline population) developed frailty. Cox's regression analysis, adjusting for 14 potential confounders showed that, compared to those using a private doctor's office, people using a public clinic for their care had a significantly higher risk of developing frailty (HR = 1.56; 95%CI: 1.07-2.70), similar to those using HMO (HR = 1.48; 95%CI: 1.03-2.24) and those using a hospital/ED (HR = 1.76; 95%CI: 1.03-3.02). CONCLUSION: Participants receiving health care from sources other than private doctors are at increased risk of frailty, highlighting the need for screening for frailty in these health settings.

Prevalence and impact of Clostridium difficile infection in elderly residents of long-term care facilities, 2011: A nationwide study.

The elderly population is particularly vulnerable to Clostridium difficile infection (CDI), but the epidemiology of CDI in long-term care facilities (LTCFs) is unknown.We performed a retrospective cohort study and used US 2011 LTCF resident data from the Minimum Data Set 3.0 linked to Medicare claims. We extracted CDI cases based on International Classification of Diseases-9 coding, and compared residents with the diagnosis of CDI to those who did not have a CDI diagnosis during their LTCF stay. We estimated CDI prevalence rates and calculated 3-month mortality rates.The study population consisted of 2,190,613 admissions (median age 82 years; interquartile range 76-88; female to male ratio 2:1; >80% whites), 45,500 of whom had a CDI diagnosis. The nationwide CDI prevalence rate was 1.85 per 100 LTCF admissions (95% confidence interval [CI] 1.83-1.87). The CDI rate was lower in the South (1.54%; 95% CI 1.51-1.57) and higher in the Northeast (2.29%; 95% CI 2.25-2.33). Older age, white race, presence of a feeding tube, unhealed pressure ulcers, end-stage renal disease, cirrhosis, bowel incontinence, prior tracheostomy, chemotherapy, and chronic obstructive pulmonary disease were independently related to "high risk" for CDI. Residents with a CDI diagnosis were more likely to be admitted to an acute care hospital (40% vs 31%, P < 0.001) and less likely to be discharged to the community (46% vs 54%, P < 0.001) than those not reported with CDI during stay. Importantly, CDI was associated with higher mortality (24.7% vs 18.1%, P = 0.001).CDI is common among the elderly residents of LTCFs and is associated with significant increase in 3-month mortality. The prevalence is higher in the Northeast and risk stratification can be used in CDI prevention policies.

Advance directive repository.

As the population ages, end-of-life care (EOLC) becomes an increasingly pressing issue. Advance directives (ADs) are legal documents that allow individuals to convey their decisions about EOLC. Although ADs have been shown to reduce EOLC costs, most people do not have ADs. To address this issue, we recently proposed that Congress instruct the Centers for Medicare and Medicaid Services (CMS) to collect ADs from Medicare beneficiaries. Herein, we outline how to implement this solution.

Mandating advance directives.

As the population ages, end-of-life care (EOLC) costs become an increasingly pressing subject. Advance directives (ADs) are legal documents that allow individuals to convey their decisions about EOLC. Although ADs have been shown to reduce EOLC costs, most people do not have ADs. To address this issue, we propose that Congress instruct the Centers for Medicare and Medicaid Services to collect ADs from Medicare beneficiaries. Because ADs can improve care and reduce unnecessary spending, this solution would likely be attractive to a broad coalition of support from providers, insurers, and the public.

Stroke prevention in atrial fibrillation in older adults: existing knowledge gaps and areas for innovation: a summary of an American Federation for Aging research seminar.

Atrial fibrillation (AF) is a common and morbid cardiac arrhythmia that increases in prevalence with advancing age. The risk of ischemic stroke, a primary and disabling hazard of AF, also increases with advancing age. The aging of the population is anticipated to contribute to a rising burden of AF-related morbidity and economic costs, given the close association between the arrhythmia and aging. Recent biological, diagnostic, and therapeutic developments raise hope that AF-related stroke can be largely prevented, yet despite advances in stroke prevention for individuals with AF, numerous scientific and clinical knowledge gaps remain, particularly as these developments are applied to older adults. Given the public health importance of AF-related stroke in elderly adults, a group of clinician-investigators convened on April 5, 2012, to identify promising areas for investigation that may ultimately reduce stroke-related morbidity. This article summarizes the meeting discussion and emphasizes innovative topic areas that may ultimately facilitate the application of novel preventive, diagnostic, and therapeutic insights into the management of older adults with AF. The opinions of those that participated in the meeting limit this report, which may not represent all of the questions that other experts in this field might raise.

Cadaver treasure hunt: introducing geriatrics concepts in the anatomy class.

The objective of this study was to develop an educational program introducing geriatrics to medical students during anatomy. Observational study of an educational intervention in medical school was the design utilized. First-year medical students in an anatomy laboratory were participants. The program consists of a lecture and a workshop. First, a geriatrics lecture early in the course presents demographic data on the cadavers, followed by comparison with national data on leading causes of death. Second, there is a "treasure hunt" in the anatomy laboratory conducted by geriatricians. Each geriatrician spends 45 minutes with one-four-student cadaver group at a time, reviewing anatomical findings and facilitating a discussion of clinical correlations and implications. A list of common anatomical findings, aging- and disease-related, is distributed to the students as an aid in identifying findings of interest. Students have been surprised to learn that the mean age of the 24 cadavers exceeded 80 years (mean 81, median 85 for 2 years), and that causes of death mirrored national data. The students begin understanding aging and appreciate the valuable resource of cadavers. The students acquire a new holistic perspective regarding their cadavers that is not apparent during the dissections. Students and faculty find the experience valuable in understanding the interplay of disease and aging. Evaluations have been mostly positive (82-87% positive responses). The anatomy lecture and "treasure hunt" experience are unique strategies for using cadavers to introduce geriatrics principles into the medical school.

Integrating and evaluating geriatrics in medical school: a novel approach for the challenge.

Brown Medical School developed a comprehensive curriculum in which enriched aging content increased from 22 to 80 hours in preclerkship courses and was also added for clerkships, residencies, and nongeriatrician physicians. Innovative evaluation strategies are also described. Highlights include "treasure hunts" in the anatomy laboratory, a Scholarly Concentration in Aging, Schwartz Communication Sessions, a Website of aging-related materials, and a monthly column in the state medical journal. Evaluation includes "tracking" to compute the "dose" of aging content, and "journaling" and focus groups to evaluate students' responses. Integrating geriatrics across a broad range of courses and clinical experiences is feasible.

Teaching communication and compassionate care skills: an innovative curriculum for pre-clerkship medical students.

BACKGROUND: Physicians require communications training to improve effective and compassionate care. Clinicians discuss challenging communication issues in existing hospital "Schwartz Rounds." AIMS: To improve communication skills, the Warren Alpert Medical School of Brown University designed "Schwartz Communication Sessions" for the mandatory 2-year pre-clerkship Doctoring course. Alongside learning interviewing, physical examination, and professionalism skills, the new Schwartz curriculum provides medical students with the rationale and proficiency for effective communication with patients, families and the healthcare team. METHODS: First-year students experience a graduated curriculum of three sessions on themes such as empathy and professionalism using innovative methods. Sessions highlight cases and videos depicting successful and ineffective interactions, large and small group discussions, role play and skills practice, guest patient presentations, and multi-disciplinary panels. The second-year students' session focuses on communications with challenging patients. RESULTS: Students and faculty rate the sessions highly on effectiveness of enhancing communication skills, gaining perspective in healthcare communication, and appreciating the complexities of healthcare situations. Expansion of the program using case-based sessions for clerkship students is planned for a continuous and graduated experience. CONCLUSIONS: Integrating a pre-clerkship communications curriculum may help improve future physicians' interactions with patients and families. Implications of this curriculum for medical education are discussed.

A systematic review of curricular interventions teaching transitional care to physicians-in-training and physicians.

PURPOSE: To systematically review and describe published interventions about teaching continuity-of-care best practices, embodied by transitional care, to physician-trainees and physicians. METHOD: The authors performed a systematic review of interventions indexed in PubMed, ISI Web of Science, Educational Resources Information Center, professional society Web sites, education databases, and hand-selected references. English-language articles published between 1973 and 2010 that demonstrated purposeful, directed education of physician-trainees and physicians on topics consistent with the contemporary definition of transitional care were included. Abstracted data included intended audience, duration/intensity, objectives, resources used, learner assessment, and curricular evaluation method. RESULTS: A dramatic increase in the number of published interventions teaching transitional care was noted in the last 10 years. Learners included preclinical medical students through attending physicians and also included allied health professionals. Brief, self-limited interactions in large groups were the most frequent mode of interaction. A wide array of objectives and resources used were represented. Most interventions provided a method for assessing knowledge acquisition by the learner; however, few interventions provided a mechanism for eliciting feedback from learners. CONCLUSIONS: Proficiency in providing transitional care is an essential skill for medical practitioners. Historically, there have been few curricular interventions teaching this topic; however, recently a dramatic increase in the number of interventions has occurred. A diverse range of learners, modes of delivery, and intended objectives are represented. In establishing a pooled description of published interventions, this review provides a comprehensive and novel resource for educators charged with designing curricula for all medical professionals.