B. Josea Kramer

The Interdisciplinary Team in Geriatric Care

Clinical geriatrics and interdisciplinary team care approaches have coevolved during the past 30 years. It has become an article of faith in geriatrics that the goal of multidimensional health for frail elderly patients is most effectively pursued by the interdisciplinary health care team. Geriatrics team models have recently become increasingly differentiated, following secular changes in the health care system that promote community-based care and research findings supporting the efficacy of team-based geriatric services. This article describes a number of these diverse models and evidence of their efficacy and ventures some thoughts on the position of geriatric teams within the more general emergence of primary, managed care models of health services delivery.

Veterans Health Administration and Indian Health Service: Healthcare Utilization by Indian Health Service Enrollees

Background:The Veterans Health Administration (VHA) and Indian Health Service (IHS) have executed an agreement to share resources to improve access and health outcomes for American Indian and Alaska Native (AIAN) veterans. Objectives:To describe the extent of dual use, health needs, and utilization patterns for IHS-enrollees served by VHA and IHS. Our objective is to fill those gaps in knowledge to inform strategic planning between these federal agencies. Methods:Secondary data analysis of linked and merged VHA and IHS centralized administrative data from FY02 and FY03. Results:Of 64,746 IHS enrollees who used VHA and/or IHS, 25% accessed care at both healthcare organizations, whereas most used either the VHA (28%) or the IHS (46%). The proportion of dual users varied markedly by state. Like all other VHA users, these AIAN veterans have the same 3 most frequent diagnoses associated with healthcare encounters: posttraumatic stress disorder, hypertension, and diabetes. VHA-IHS dual users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VHA. Many dual users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping attention in VHA and IHS. Conclusions:Strategies to improve outcomes for AIAN veterans should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts. Strategies to improve access may differ regionally.

Dual Use of Veterans Health Administration and Indian Health Service: Healthcare Provider and Patient Perspectives

ABSTRACTBACKGROUNDMany American Indian and Alaska Native veterans are eligible for healthcare from Veterans Health Administration (VHA) and from Indian Health Service (IHS). These organizations executed a Memorandum of Understanding in 2003 to share resources, but little was known about how they collaborated to deliver healthcare.OBJECTIVETo describe dual use from the stakeholders’ perspectives, including incentives that encourage cross-use, which organization’s primary care is “primary,” and the potential problems and opportunities for care coordination across VHA and IHS.PARTICIPANTSVHA healthcare staff, IHS healthcare staff and American Indian and Alaska Native veterans.APPROACHFocus groups were conducted using a semi-structured guide. A software-assisted text analysis was performed using grounded theory to develop analytic categories.MAIN RESULTSDual use was driven by variation in institutional resources, leading patients to actively manage health-seeking behaviors and IHS providers to make ad hoc recommendations for veterans to seek care at VHA. IHS was the “primary” primary care for dual users. There was little coordination between VHA and IHS resulting in delays and treatment conflicts, but all stakeholder groups welcomed future collaboration.CONCLUSIONSFostering closer alignment between VHA and IHS would reduce care fragmentation and improve accountability for patient care.

Health care for American Indian and Alaska native women.

BACKGROUND Many American Indian and Alaska Native (AIAN) women serve in the military and are eligible for healthcare from both the Veterans Health Administration (VHA) and the Indian Health Service (IHS). Little was known about these womens patterns of health care utilization when VHA and IHS executed a resource-sharing agreement in 2003 to improve access and health outcomes. OBJECTIVE We sought to describe womens healthcare utilization in VHA and IHS. METHODS We conducted a descriptive secondary data analysis of linked IHS and VHA administrative records from fiscal years 2002 and 2003 for women among all IHS beneficiaries who were veterans or used VHA for health care (n = 64,746). RESULTS Among these IHS beneficiaries, 4,338 (6.7%) were female veterans and 1,518 (2.8%) were female nonveterans. Comparing IHS services to VHA, the VHA provided the majority of outpatient specialty care to veterans, providing 89.9% of diagnostic and imaging services, 84.4% of mental health care, and 78.1% of physical medicine and rehabilitation. Conversely, the IHS provided the majority of ambulatory and inpatient care for obstetrics and gynecology to these veterans. Dual users received primary care from both organizations. Nonveterans generally accessed VHA under sharing agreements and their use of health care was generally limited to outpatient diagnostic and imaging. CONCLUSIONS The VHA seems to supplement healthcare provided by the IHS for female AIAN veterans, as well as for a small proportion of nonveterans. The VHA and the IHS have developed specialized and complementary expertise, which might be aligned to serve the needs of female AIAN veterans.

AN ATTEMPT TO CHARACTERIZE FACTORS THAT AFFECT PARTICIPATION IN MINIMAL-RISK RESEARCH OF OLDER ADULTS : WHAT CAN WE LEARN FROM PUBLISHED RESEARCH FINDINGS?

To the Editor: Older adults are less likely than younger adults to participate in research. It remains unclear, however, whether this difference is due to recruitment issues, consent processes, eligibility criteria, participant burden or other factors.1,2 Each of these issues may affect research design, sample representativeness and, ultimately, the ability to generalize research findings to an older adult population. In an effort to understand contemporary factors that may influence decisions to participate in minimal risk research, we systematically reviewed 59 clinical investigations published in the Journal of the American Geriatrics Society over a 6-month period (August 2006-January 2007). Our goals in conducting this literature review were: 1) to estimate the proportion of older adults that were invited, but refused to participate in minimal-risk research; 2) to determine what factors reportedly were associated with refusal to participate. Of the 59 articles considered, 29 met criteria for review (see Table 1); that is, the studies were conducted in the U.S., required consent/assent and were minimal risk. Retrospective and anonymous survey studies were excluded. Studies were most often excluded because they were conducted outside of the U.S. Two independent raters (RV and JM) completed a structured abstraction form to identify level of risk (minimal versus greater than minimal risk, based on current National Institutes of Health guidelines).3 We attempted to abstract rates of participant refusal and reasons for refusal from the articles as well. Refusals were coded separately from other non-participation factors, such as ineligibility, “failure to contact” or withdrawal after consent. Unfortunately, refusal information was seldom explicitly stated, resulting in a low inter-rater agreement (50%) between reviewers. That difficulty was resolved by using a 3-person consensus panel (RV, JM, JK) to re-evaluate all studies. About one-third of the articles reported refusal rates and none of the articles described actual reasons for refusal. When reported, the average refusal rate across studies was 29% (SD=17%). Seven articles referenced other published sources for more detailed methodological information, but only two of these secondary sources provided additional information on participant refusals. Participants and refusers were compared in 10% (n=3) of articles, and these studies found that a) African-Americans, and/or older potential participants were less likely to participate, or b) there were no apparent differences between consenters and non-consenters.2,4,5 To develop insight into how the research topic might impact participation, the 3-person panel categorized studies by type of outcome: 1) functional status (i.e., basic/instrumental activities of daily living, n=11); 2) health and healthcare related outcomes (i.e., specific diagnoses, healthcare utilization, dietary supplements, n=16); and 3) subjective/opinion studies (i.e., perceptions of care quality, patient opinions, n=2). When compared, there were no statistical differences in refusal rates across study types. However, studies of functional status tended to report refusal rates more often (55%) than studies of health and healthcare (19%). Functional status studies had higher actual refusal rates (34%) than health related studies (21%). Basic information on human subjects issues (e.g., informed consent, institutional review board approval) was also abstracted. Strikingly, we found that “informed consent” was mentioned in only 69% (n=20) of articles despite explicit instructions to authors6 to include this information in the Methods section of submitted papers.

A Multisite Geriatric Education Program for Rural Providers in the Veteran Health Care System (GRECC-Connect)

Older patients who live in rural areas often have limited access to specialty geriatric care, which can help in identifying and managing geriatric conditions associated with functional decline. Implementation of geriatric-focused practices among rural primary care providers has been limited, because rural providers often lack access to training in geriatrics and to geriatricians for consultation. To bridge this gap, four Geriatric Research, Education, and Clinical Centers, which are centers of excellence across the nation for geriatric care within the Veteran health system, have developed a program utilizing telemedicine to connect with rural providers to improve access to specialized geriatric interdisciplinary care. In addition, case-based education via teleconferencing using cases brought by rural providers was developed to complement the clinical implementation efforts. In this article, the authors review these educational approaches in the implementation of the clinical interventions and discuss the potential advantages in improving implementation efforts.

Identification of American Indian and Alaska Native Veterans in Administrative Data of the Veterans Health Administration and the Indian Health Service

We sought to determine the extent to which the Indian Health Service (IHS) identified enrollees who also use the Veterans Health Administration (VHA) as veterans. We used a bivariate analysis of administrative data from fiscal years 2002-2003 to study the target population. Of the 32259 IHS enrollees who received care as veterans in the VHA, only 44% were identified by IHS as veterans. IHS data underestimates the number of veterans, and both IHS and VHA need mechanisms to recognize mutual beneficiaries in order to facilitate better coordination of strategic planning and resource sharing among federal health care agencies.

Medical House staff Performance on the Facts of Aging Quiz

Abstract The Facts on Aging Quiz (FAQ) is a self-administered quiz that has been used to measure gerontological knowledge. The release of a multiple-choice version of the FAQ provided the opportunity to compare performance of medical housestaff on the true-false and multiple-choice formats. This cross-sectional study evaluated performance of medical housestaff on the true-false version and on the multiple choice format. To understand selection of responses, an additional sample of medical housestaff were debriefed on their choices of answers to the true-false version. Findings show that the true-false format produced significantly more correct responses than the multiple-choice version, and that physician performance on the FAQ varied with format of the quiz. The FAQ may not be a relevant instrument for determining knowledge of medical post-graduate residency trainees.

Veterans Affairs Geriatric Scholars Program: Enhancing Existing Primary Care Clinician Skills in Caring for Older Veterans

The Veterans Affairs Geriatric Scholars Program (GSP) is a continuing professional development program to integrate geriatrics into the clinical practices of primary care providers and select associated health professions that support primary care teams. GSP uses a blended program educational format, and the minimal requirements are to attend an intensive course in geriatrics, participate in an interactive workshop on quality improvement (QI), and initiate a local QI project to demonstrate application of new knowledge to benefit older veterans. Using a retrospective post/pre survey design, the effect of GSP on clinical practices and behaviors and variation of that effect on clinicians working in rural and nonrural settings were evaluated. Significant improvement was found in the frequency of using evidence‐based brief standardized assessments, clinical decision‐making, and standards of care. Significant subgroup differences were observed in peer‐to‐peer information sharing between rural and nonrural clinicians. Overall, 77% of the sample reported greater job satisfaction after participating in GSP. The program is a successful model for advancing postgraduate education in geriatrics and a model that might be replicated to increase access to quality health care, particularly in rural areas.

Development of the Usability of Sleep Apnea Equipment - Positive Airway Pressure (USE-PAP) questionnaire

BACKGROUND A growing number of positive airway pressure (PAP) device users will develop physical/sensory impairments such as arthritis. For these individuals, the usability of their PAP devices (e.g., efficiency and satisfaction) may impact the frequency and safety of device usage. Questionnaires to assess PAP usability are unavailable; therefore, we developed the Usability of Sleep Apnea Equipment-Positive Airway Pressure (USE-PAP) questionnaire. METHODS Questionnaire development included in-depth interviews to identify relevant content areas, a technical advisory panel to review/edit items, cognitive interviews to refine items, and a cross-sectional survey of Veterans Affairs sleep clinic patients assessing PAP device usability overall (one multi-item scale), usability of PAP components (multi-item scales for machine controls, mask/headgear, tubing, and humidifier), frequency of usability-related issues (one multi-item scale), PAP device characteristics, and demographics. RESULTS After conducting 19 in-depth interviews, a panel meeting, and 10 cognitive interviews, we administered the survey to 100 PAP device users (67% ≥60 years; 90% male). The items assessing machine control usability received the least favorable ratings. Twenty percent of respondents reported difficulty getting equipment ready for use, and 33 percent had difficulty cleaning equipment. The six multi-item scales had excellent internal consistency reliability (alpha ≥0.84) and item-rest correlations (≥0.39). CONCLUSIONS This study provides initial support for the USE-PAP for measuring PAP device usability. Studies that include large samples are needed to further evaluate the psychometric properties of the USE-PAP. In addition, comparisons of USE-PAP responses with direct observations of PAP-related tasks and objectively measured PAP adherence are needed to fully evaluate the questionnaire.