Christian Nouryan

The Impact of Remote Patient Monitoring (Telehealth) upon Medicare Beneficiaries with Heart Failure

OBJECTIVE To study the impact of remote patient monitoring (RPM) upon the most frequent diagnosis in hospitalized patients over 65 years of age-heart failure (HF). We examined the effect of RPM on hospital utilization and Medicare costs of HF patients receiving home care. MATERIALS AND METHODS Two studies were simultaneously conducted: A randomized and a matched-cohort study. In the randomized study, 168 subjects were randomly assigned (after hospitalization) to home care utilizing RPM (live nursing visits and video-based nursing visits) or to home care receiving live nursing visits only. In the matched-cohort study, 160 subjects receiving home care with RPM (live nursing visits and video-based nursing visits) were matched with home care subjects receiving live nursing visits only. RESULTS Regardless of whether outcomes were being analyzed for all subjects (intention to treat) or for hospitalized subjects only, hospitalization rates, time to first admission, length of stay, and costs to Medicare did not differ significantly between groups in either study at 30 or 90 days after enrollment. A notable trend, however, emerged across studies: Although time to hospitalization was shorter in the RPM groups than the control groups, RPM groups had lower hospitalization costs. CONCLUSIONS RPM, when utilized in conjunction with a robust management protocol, was not found to significantly differ from live nursing visits in the management of HF in home care. Shorter hospitalization times and lower associated costs may be due to earlier identification of exacerbation. These trends indicate the need for further study.

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 teams 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.

Do residents need end-of-life care training?

OBJECTIVE As medical education evolves, emphasis on chronic care management within the medical curriculum becomes essential. Because of the consistent lack of appropriate end-of-life care training, far too many patients die without the benefits of hospice care. This study explores the association between physician knowledge, training status, and level of comfort with hospice care referral of terminally ill patients. METHOD In 2011, anonymous surveys were distributed to physicians in postgraduate years 1, 2, and 3; fellows; hospital attending physicians; specialists; and other healthcare professionals in five hospitals of a large health system in New York. Demographic comparisons were performed using χ2 and Fishers exact tests. Spearman correlations were calculated to determine if professional status and experience were associated with comfort and knowledge discussing end-of-life topics with terminal patients. RESULTS The sample consisted of 280 participants (46.7% response rate). Almost a quarter (22%) did not know key hospice referral criteria. Although 88% of respondents felt that knowledge of hospice care is an important competence, 53.2% still relinquished advance directives discussion to emergency room (ER) physicians. Fear of patient/family anger was the most frequently reported hospice referral barrier, although 96% of physicians rarely experienced reprisals. Physician comfort level discussing end-of-life issues and hospice referral was significantly associated with the number of years practicing medicine and professional status. SIGNIFICANCE OF RESULTS Physicians continue to relinquish end-of-life care to ER staff and palliative care consultants. Exploring unfounded and preconceived fears associated with hospice referral needs to be integrated into the curriculum, to prepare future generations of physicians. Medical education should focus on delivering the right amount of end-of-life care training, at the right time, within the medical school and residency curriculum.

Survey of Emergency Medical Services Professionals’ Experience with Advance Directives and Medical Orders for Life-Sustaining Treatment

1. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 38). BMJ 1998;317:703–713. 2. Whitmer RA, Karter AJ, Yaffe K et al. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA 2009;301:1565–1572. 3. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med 2003;348:42–49. 4. Huang ES, Karter AJ, Danielson KK et al. The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: The diabetes and aging study. J Gen Intern Med 2010;25:141–146. Epub 2009 Dec 5. 5. Calles-Escandón J, Lovato LC, Simons-Morton DG et al. Effect of intensive compared with standard glycemia treatment strategies on mortality by baseline subgroup characteristics: The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Diabetes Care 2010;33:721–727. 6. American Diabetes Association: Standards of medical care in diabetes— 2011. Diabetes Care 2011;34 (Suppl 1):S11–S61. 7. Brown AF, Mangione CM, Saliba D et al. Guidelines for improving the care of the older individual with diabetes mellitus. J Am Geriatr Soc 2003;51 (Suppl):S265–S280. 8. Pogach L, Conlin PR, Hobbs C et al.; for the VA-DoD Diabetes Guideline Working Group. What clinicians need to know about absolute risk of benefits and harms of A1c laboratory accuracy. Federal Practitioner 2011;39: 39–44.

A Multisite Validity Study of Self-Reported Anesthesia Outcomes

The purpose of this study was to assess the validity of a multisite anesthesia voluntary adverse event reporting process. A data validation methodology was used through medical chart review on live records at 3 facilities (N = 600). The per-item aggregated error rate among all 42 data items was 0.3%: 0.1% for quality indicators, 1.3% for demographic/status variables, and 1.7% for administrative items. The per-patient error rate among all 42 data items was 6.3%: 3.0% for quality indicators, 1.7% for demographic/status variables, and 3.0% for administrative items. Trends such as better accuracy for more serious events continue, but observed error rates were lower than those found in previous surveys—an indication that, while further study is needed, nonpunitive voluntary reporting may reduce errors in anesthesia care.

Opiate Prescribing in Hospitalized Older Adults: Patterns and Outcomes

Whereas opiate prescribing patterns have been well described in outpatient and emergency department settings, they have been less defined in hospitalized older adults. The objective was to describe patterns of opiate prescribing and associated outcomes in hospitalized older adults.

Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”?

To evaluate physician knowledge and perceptions about the American Board of Internal Medicine/American Geriatrics Society (ABIM/AGS) Choosing Wisely recommendations regarding percutaneous endoscopic gastrostomy (PEG) in individuals with advanced dementia.

Health providers’ perspectives on medical marijuana use.

235Background: According to the CDC, 117 million Americans have one or more chronic health conditions and 31% have used two or more prescription drugs in the past month. Approximately 40% of adults in the United States are using some form of Complementary and Alternative Medicine. Medical marijuana is one such medicine, and to date 29 states have legalized medical marijuana. Methods: A multicenter, anonymous, on-line survey of health care providers was distributed via e-mail within a large health system in the NY Metropolitan area. The survey was distributed in April and May of 2017. The specific aim was to collect information about health care providers’ perspectives on the use of MM in general and for specific medical conditions. Results: The sample (n = 137) consisted of 4% RNs, 10% NPs, 10% fellows, 21% resident physicians, and 52% attending physicians. Average experience was 13 years (range: 0-43), half (53%) were under 40 years old and just over half (56%) were female. Most practitioners recognized ...