RESUMO
At a time when the older adult population is increasing exponentially and health care agencies are fraught with crisis-level short-handedness and burnout, addressing the Quadruple Aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers is more crucial than ever. A multi-step education model was designed to advance competencies in geriatrics and Interprofessional Collaborative Practice (IPCP) for health profession students focused on each element of the Quadruple Aim. The goals of this education were to equip students with knowledge and experience to provide team-based care for older adults and achieve satisfaction with the education program. The education steps consisted of online didactics, team icebreaker, skills practice, professional huddles, and interprofessional simulation with debriefing. Over 2,300 students and 87 facilitators from 16 professions completed the training over three years. A positive statistically significant increase was found between pre- and post-measures of IPCP competency, knowledge, and attitudes. Additionally, high satisfaction with the education was reported by students and facilitators. By providing positive geriatric education and experiences for health students to work in interprofessional teams, it can translate into future improvements in older adult population health, health care provider job satisfaction, and reduced health care costs.
Assuntos
Geriatria , Relações Interprofissionais , Humanos , Idoso , Equipe de Assistência ao Paciente , Geriatria/educação , EstudantesRESUMO
Though older adults are more sensitive to the effects of medications than their younger counterparts, they are often excluded from manufacturer-based clinical studies. Practice-based research is a practical method to identify medication-related effects in older patients. This research also highlights the role of a pharmacist in improving care in this population. A single study rarely has strong enough evidence to change geriatric practice, unless it is a large-scale, multisite, randomized controlled trial that specifically targets older adults. It is important to design studies that may be used in systematic reviews or meta-analyses that build a stronger evidence base. Recent literature has documented a gap in advanced pharmacist training pertaining to research skills. In this paper, we hope to fill some of the educational gaps related to research in older adults. We define best practices when deciding on the type of study, inclusion and exclusion criteria, design of the intervention, how outcomes are measured, and how results are reported. Well-designed studies increase the pool of available data to further document the important role that pharmacists have in optimizing care of older patients.
Assuntos
Avaliação de Resultados em Cuidados de Saúde , Farmacêuticos , Papel Profissional , Projetos de Pesquisa , Idoso , Humanos , Metanálise como Assunto , Literatura de Revisão como AssuntoRESUMO
Antimicrobial stewardship of anti-infectives prescribed upon hospital discharge was implemented to improve the rate of appropriate prescribing at discharge. Appropriate prescribing significantly improved from 47.5% to 85.2% (P < .001), antimicrobial days of therapy decreased, and 30-day readmission rates decreased. Discharge antimicrobial stewardship was effective in improving anti-infective prescribing practices.
Assuntos
Gestão de Antimicrobianos , Antibacterianos/uso terapêutico , Hospitais , Humanos , Alta do Paciente , Readmissão do PacienteRESUMO
Guideline-recommended anticoagulation is frequently omitted in high-risk patients with atrial fibrillation (AF) for reasons not fully understood, which may result in suboptimal care. A nationally representative, expert group of physicians (cardiology, neurology, and general medicine), and clinical pharmacists participated in a consensus-seeking, modified Delphi method to identify key clinical decision-making factors driving anticoagulant prescribing in real-world AF patients. Representing >2,500 anticoagulation-related patient encounters per month, 27 of 30 participants completed the study (90% overall response rate). In Round-1, experts rated their level of agreement with factors and suggested modifications or additional factors. Of 66 factors entering Round-1, 21 met and 4 partially met consensus, 41 did not meet consensus, and 7 were newly suggested. Of 32 factors advanced for scoring in Round-2, 16 met consensus criteria. In Round-3, experts were given the option to rescue up to 2 of the 16 nonconsensus factors from Round-2. Including a concomitant need for dual antiplatelet therapy, no factor was successfully rescued into consensus. The most important factors related to risk of infarction rather than bleeding risk or other patient-specific considerations. Among factors not independently addressed in current guidelines, these included baseline hematologic indicators of potential bleeding risk, previous bleeding episodes by specific type, other risk factors for bleeding, and adherence. In conclusion, when determining anticoagulation strategies in AF, there is a need for further research on the clinical implications of these emerging factors as well as the reasons behind divergent opinions toward nonconsensus factors.
Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Tomada de Decisão Clínica , Seleção de Pacientes , Padrões de Prática Médica , Adulto , Consenso , Técnica Delphi , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controleRESUMO
OBJECTIVE: Depression guidelines discourage benzodiazepine monotherapy and limit use to short-term adjunctive therapy with antidepressants; however, patients with depression continue to receive benzodiazepine monotherapy. The prevalence and predictors of this prescribing pattern have not been described previously and are warranted to assist clinicians in identifying patients at highest risk of receiving benzodiazepine monotherapy. METHODS: A national, cross-sectional analysis of the National Ambulatory Medical Care Survey from 2012 to 2015 was performed for adults treated for depression. Depression was identified using a survey item specifically assessing the presence of depression. Office visits involving patients with bipolar disorder, schizoaffective disorder, or pregnancy were identified by ICD-9 code or specific survey item and were excluded. The primary endpoint was benzodiazepine monotherapy prescribing rate defined as initiation or continuation of a benzodiazepine in the absence of any antidepressant agent. A multivariate logistic regression model was created to identify variables associated with benzodiazepine monotherapy. RESULTS: In total, 9,426 unweighted visits were eligible for inclusion. Benzodiazepine monotherapy was identified in 9.3% of patients treated for depression (95% CI, 8.2%-10.6%). Predictors of benzodiazepine monotherapy included age of 45-64 years (OR = 1.39; 95% CI, 1.01-1.91), epilepsy-related office visit (OR = 5.34; 95% CI, 1.39-20.44), anxiety-related office visit (OR = 1.67; 95% CI, 1.23-2.27), underlying pulmonary disease (OR = 1.43; 95% CI, 1.09-1.87), and concomitant opiate prescribing (OR = 2.86; 95% CI, 2.01-4.06). Psychiatrists were less likely to prescribe benzodiazepine monotherapy than were other providers (OR = 0.42; 95% CI, 0.29-0.61). CONCLUSIONS: Benzodiazepine monotherapy is utilized in nearly 1 in 10 patients treated for depression. Adults aged 45 to 65 years, patients prescribed opioids, patients seen by primary care providers, and those with underlying anxiety, epilepsy, or pulmonary disorders are at highest risk.
Assuntos
Ansiedade , Benzodiazepinas/uso terapêutico , Transtorno Depressivo , Epilepsia , Prescrição Inadequada , Padrões de Prática Médica , Antidepressivos/uso terapêutico , Ansiedade/diagnóstico , Ansiedade/epidemiologia , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/tratamento farmacológico , Transtorno Depressivo/epidemiologia , Transtorno Depressivo/psicologia , Uso de Medicamentos/normas , Uso de Medicamentos/estatística & dados numéricos , Epilepsia/diagnóstico , Epilepsia/epidemiologia , Feminino , Pesquisas sobre Atenção à Saúde , Pessoal de Saúde/classificação , Humanos , Prescrição Inadequada/prevenção & controle , Prescrição Inadequada/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Visita a Consultório Médico/estatística & dados numéricos , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Prevalência , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
Pharmacists in both ambulatory and institutional settings are often in a position to help optimize the drug regimens of patients who are experiencing falls. Supplementation with vitamin D is an important emerging therapy for the prevention of falls. Numerous investigators have recently studied or reviewed the association between vitamin D supplementation and decreased risk of falls in elderly patients, yet little of this information is available in the pharmacy literature. A MEDLINE search was conducted to collect relevant articles about the role of vitamin D in preventing falls among elderly patients; recently published meta-analyses and randomized controlled trials were identified and reviewed. The studies indicated a statistically significant positive relationship between vitamin D supplementation with either cholecalciferol 700 IU/day or greater or ergocalciferol 800 IU/day or greater and decreased risk of falls. Other practical issues, including who should receive vitamin D replacement, what form of vitamin D should be used, and what dosage is required to prevent falls, are discussed.
Assuntos
Acidentes por Quedas/prevenção & controle , Vitamina D/uso terapêutico , Vitaminas/uso terapêutico , Acidentes por Quedas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Cálcio/administração & dosagem , Cálcio/uso terapêutico , Colecalciferol/administração & dosagem , Colecalciferol/uso terapêutico , Ergocalciferóis/administração & dosagem , Ergocalciferóis/uso terapêutico , Humanos , Educação de Pacientes como Assunto , Assistência Farmacêutica , Vitamina D/administração & dosagem , Vitaminas/administração & dosagemRESUMO
Many medications that are safe in most patients pose serious risks in older patients, including functional decline, delirium, falls, and poorer outcomes. We describe our institution's program of "academic detailing," designed to reduce the use of three high-risk drugs in elderly patients.
Assuntos
Amitriptilina/efeitos adversos , Sistemas de Informação em Farmácia Clínica , Difenidramina/efeitos adversos , Geriatria/normas , Unidades Hospitalares/normas , Sistemas de Medicação no Hospital/normas , Meperidina/efeitos adversos , Gestão de Riscos/métodos , Gestão da Qualidade Total/métodos , Idoso , Contraindicações , Interações Medicamentosas , Humanos , OhioRESUMO
The specific aim of the PEACE pilot study was to determine the feasibility of a fully powered study to test the effectiveness of an in-home geriatrics/palliative care interdisciplinary care management intervention for improving measures of utilization, quality of care, and quality of life in enrollees of Ohio's community-based long-term care Medicaid waiver program, PASSPORT. This was a randomized pilot study (n=40 intervention [IG], n=40 usual care) involving new enrollees into PASSPORT who were >60 years old. This was an in-home interdisciplinary chronic illness care management intervention by PASSPORT care managers collaborating with a hospital-based geriatrics/palliative care specialist team and the consumer's primary care physician. This pilot was not powered to test hypotheses; instead, it was hypothesis generating. Primary outcomes measured symptom control, mood, decision making, spirituality, and quality of life. Little difference was seen in primary outcomes; however, utilization favored the IG. At 12 months, the IG had fewer hospital visits (50% vs. 55%, P=0.65) and fewer nursing facility admissions (22.5% vs. 32.5%, P=0.32). Using hospital-based specialists interfacing with a community agency to provide a team-based approach to care of consumers with chronic illnesses was found to be feasible. Lack of change in symptom control or quality of life outcome measures may be related to the tools used, as these were validated in populations closer to the end of life. Data from this pilot study will be used to calculate the sample size needed for a fully powered trial.
Assuntos
Planejamento Antecipado de Cuidados/organização & administração , Serviços de Assistência Domiciliar/organização & administração , Assistência de Longa Duração/organização & administração , Qualidade de Vida , Idoso , Idoso de 80 Anos ou mais , Feminino , Idoso Fragilizado , Avaliação Geriátrica/métodos , Promoção da Saúde , Serviços de Saúde para Idosos/organização & administração , Humanos , Comunicação Interdisciplinar , Masculino , Ohio , Cuidados Paliativos/organização & administração , Projetos Piloto , Avaliação de Programas e Projetos de Saúde , Valores de Referência , Resultado do TratamentoRESUMO
Practice guidelines are available for hospice and palliative medicine specialists and geriatricians. However, these guidelines do not adequately address the needs of patients who straddle the 2 specialties: homebound chronically ill patients. The purpose of this article is to describe the theoretical basis for the Promoting Effective Advance Care for Elders (PEACE) randomized pilot study. PEACE is an ongoing 2-group randomized pilot study (n=80) to test an in-home interdisciplinary care management intervention that combines palliative care approaches to symptom management, psychosocial and emotional support, and advance care planning with geriatric medicine approaches to optimizing function and addressing polypharmacy. The population comprises new enrollees into PASSPORT, Ohio's community-based, long-term care Medicaid waiver program. All PASSPORT enrollees have geriatric/palliative care crossover needs because they are nursing home eligible. The intervention is based on Wagner's Chronic Care Model and includes comprehensive interdisciplinary care management for these low-income frail elders with chronic illnesses, uses evidence-based protocols, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. Our model, with its standardized, evidence-based medical and psychosocial intervention protocols, will transport easily to other sites that are interested in optimizing outcomes for community-based, chronically ill older adults.
Assuntos
Doença Crônica , Idoso Fragilizado , Promoção da Saúde/organização & administração , Serviços de Assistência Domiciliar/organização & administração , Pacientes Domiciliares , Planejamento de Assistência ao Paciente/organização & administração , Idoso , Idoso de 80 Anos ou mais , Definição da Elegibilidade , Medicina Baseada em Evidências , Feminino , Avaliação Geriátrica , Humanos , Masculino , Medicaid , Ohio , Cuidados Paliativos , Projetos Piloto , Pobreza , Projetos de Pesquisa , Apoio Social , Estados UnidosRESUMO
Interdisciplinary care management is advocated for optimal care of patients with many types of chronic illnesses; however, few models exist that have been tested using randomized trials. The purpose of this report is to describe the theoretical basis for the After Discharge Management of Low Income Frail Elderly (AD-LIFE) trial, which is an ongoing 2-group randomized trial (total n = 530) to test a chronic illness management and transitional care intervention. The intervention is based on Wagner's chronic illness care model and involves comprehensive posthospitalization nurse-led interdisciplinary care management for low income frail elders with chronic illnesses, employs evidence-based protocols that were developed using the Assessing Care of Vulnerable Elders (ACOVE) guidelines, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. The primary aim of the AD-LIFE trial is to test a chronic illness management intervention in vulnerable patients who are eligible for Medicare and Medicaid. This model, with its standardized, evidence-based medical and psychosocial intervention protocols, will be easily transportable to other sites interested in optimizing outcomes for chronically ill older adults. If the results of the AD-LIFE trial demonstrate the superiority of the intervention, then this data will be important for health care policy makers.