Preoperative Noninvasive Cardiac Testing in Older Adults with Hip Fracture: A Multi-Site Study.

BACKGROUND/OBJECTIVES: For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture. DESIGN: Retrospective chart review. SETTING: Seven hospitals (three tertiary, four community) within a large health system. PARTICIPANTS: Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married). MEASUREMENTS: Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality. RESULTS: Although 34.3% (n = 370) had a preoperative TTE, .7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] = .8-1.8 days), median LOS was 5.3 days (IQR = 4.2-7.2 days), and in-hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P < .001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P < .001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P < .001). No difference in mortality was found between patients with and without a preoperative TTE. CONCLUSION: This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population. J Am Geriatr Soc 68:1690-1697, 2020.

Medical orders for life-sustaining treatment: is it time yet?

OBJECTIVE: As the aging population faces complex end-of-life issues, we studied the intervals between long-term care admission and advance directive completion, and between completion and death. We also sought to determine the interdisciplinary team's compliance with documented wishes. METHOD: A cross-sectional study of 182 long-term care residents in two facilities with and without completed medical orders for life-sustaining treatment (MOLST) in the New York Metropolitan area was conducted. Demographic variables included: gender, age, ethnicity, and diagnosis. Measures included: admission date, MOLST execution date, and date of death. Resident advance directive documentation was compared with clinical intervention at time of death, including intubation and mechanical ventilation. RESULTS: Of the residents studied, 68.7% were female, 91% were Caucasian and 91.8% were ≥ 65 years of age (mean age: 83). The median time from admission to MOLST signing was 48 days. Median time from admission to MOLST signing for Caucasians was 21 days; for non-Caucasians was 229 days. Fifty-two percent of MOLST were signed by children, and 24% by residents. Of those with signed forms, 25% signed on day of admission, 37% signed within 7 days, and 47% signed within 21 days. Only 3% of residents died the day their MOLST was signed, whereas 12% died within a week, and 22% died within 30 days. Finally, among the 68 subjects who signed a MOLST and died, 87% had their wishes met. SIGNIFICANCE OF RESULTS: In this era of growing time constraints and increased regulations, medical directors of long-term care facilities and those team members caring for residents urgently need a clear and simple approach to the goals of care for their residents. The MOLST is an ideal tool in caring for older adults at the end of life, providing concrete guidance, not only with regard to do not resuscitate (DNR) and do not intubate (DNI) orders, but also for practical approaches to daily care for the interdisciplinary team.

Ethnicity, race, and advance directives in an inpatient palliative care consultation service.

OBJECTIVE: Although race and ethnic background are known to be important factors in the completion of advance directives, there is a dearth of literature specifically investigating the effect of race and ethnicity on advance directive completion rate after palliative care consultation (PCC). METHOD: A chart review of all patients seen by the PCC service in an academic hospital over a 9-month period was performed. Data were compiled using gender, race, ethnicity, religion, and primary diagnosis. For this study, advance directives were defined as: "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI). RESULTS: Of the 400 medical records reviewed, 57% of patients were female and 71.3% documented their religion as Christian. The most common documented diagnosis was cancer (39.5%). Forty-seven percent reported their race as white. White patients completed more advance directives than did nonwhite patients both before (25.67% vs. 12.68%) and after (59.36% vs. 40.84%) PCC. There was a significantly higher proportion of whites who signed an advance directive after a PCC than of nonwhites (p = 0.021); of the 139 whites who did not have an advance directive at admission, 63 signed an advance directive after a PCC compared with 186/60 nonwhites (45% vs. 32%, respectively, p = 0.021). Further analysis revealed that African Americans differed from whites in the likelihood of advance directive execution rates pre-PCC, but not post-PCC. SIGNIFICANCE OF RESULTS: This study demonstrates the impact of a PCC on the completion of advance directives, on both whites and nonwhites. The PCC Intervention significantly reduced differences between whites and African Americans in completing advance directives, which have been consistently documented in the end-of-life literature.

Factors influencing older adults to complete advance directives.

OBJECTIVE: The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults. METHOD: Direct interviews of hospitalized and community-dwelling cognitively intact patients > 65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives. We identified five variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables. RESULTS: Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p < 0.0002), age (p < 0.0161), race (p < 0.0001), education (p < 0.0039), and religion (p < 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3, p < 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2, p < 0.0001), having undergone major surgery (OR 6.3, p < 0.0017), female gender (OR 11.1, p < 0.0001) and increasing age (76-85 vs. 59-75: OR 3.4, p < 0.0543; < 85 vs. 59-75: OR 6.3, p < 0.0263). SIGNIFICANCE OF RESULTS: This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.

Do geriatricians practice what they preach?: geriatricians' personal establishment of advance directives.

Previous research has been conducted regarding preferences of physicians for life-sustaining treatments for themselves, but there is a dearth of data on personal use of advance directives (ADs) by geriatricians specifically. Using a phone survey, we contacted all graduates of the geriatric fellowship program to assess their personal use of advance directives and their personal preferences for life-sustaining treatment. Of the 124 living graduates of the Parker Jewish Institute for Health Care and Rehabilitation, 70 agreed to participate. One third of respondents had established ADs for themselves, with higher rates in women than men (p = .054). Older geriatricians were significantly more likely to have advance directives (exact trend test yields, p < .0001). In general, respondents did not inform their health care providers about their desires for end-of-life care. This study revealed that the majority of fellowship-trained geriatricians did not formally establish advance directives for themselves. Further research is needed to determine whether physicians who establish advance directives for themselves are more likely to encourage their patients to do so.

Do geriatricians stay in geriatrics?.

To evaluate whether formally trained geriatricians remain in the field of Geriatrics, and to determine their job satisfaction and perceived quality of life, we surveyed the 107 fellows trained over the last 25 years in one accredited geriatric program. Of the 88 physicians who consented to participate, 75% devoted at least half of their practice to the care of the elderly. On an academic level, 89.5% had, or planned to pursue, recertification in geriatric medicine. Ninety-five percent of these geriatricians felt that the impact of a formal geriatric fellowship was positive on their medical career and satisfaction index. Sixty-four percent had yearly incomes between $100 and $200k, and 25.6% had income greater than $200k. Eighty-seven percent would recommend pursuing geriatric fellowship training. We need to further explore how recruitment process and job opportunities are presented to potential geriatric fellows.