Constance H. Fung

Multimorbidity is associated with better quality of care among vulnerable elders

Background: Older patients with multiple chronic conditions may be at higher risk of receiving poorer overall quality of care compared with those with single or no chronic conditions. Possible reasons include competing guidelines for individual conditions, burden of numerous recommendations, and difficulty implementing treatments for multiple conditions. Objectives: We sought to determine whether coexisting combinations of 8 common chronic conditions (hypertension, coronary artery disease, chronic obstructive pulmonary disease, osteoarthritis, diabetes mellitus, depression, osteoporosis, and having atrial fibrillation or congestive heart failure) are associated with overall quality of care among vulnerable older patients. Materials and Methods: Using an observational cohort study, we enrolled 372 community-dwelling persons 65 years of age or older who were at increased risk for death or functional decline within 2 years. We included (1) a comprehensive measure (% of quality indicators satisfied) of quality of medical and geriatric care that accounted for patient preference and appropriateness in light of limited life expectancy and advanced dementia, and (2) a measure of multimorbidity, either as a simple count of conditions or as a combination of specific conditions. Results: Multimorbidity was associated with greaer overall quality scores: mean proportion of quality indicators satisfied increased from 47% for elders with none of the prespecified conditions to 59% for those with 5 or 6 conditions (P < 0.0001), after controlling for number of office visits. Patients with greater multimorbidity also received care that was better than would be expected based on the specific set of quality indicators they triggered. Conclusions: Among older persons at increased risk of death or functional decline, multimorbidity results in better, rather than worse, quality of care.

The Effectiveness of Radioactive Iodine for Treatment of Low-Risk Thyroid Cancer: A Systematic Analysis of the Peer-Reviewed Literature from 1966 to April 2008

BACKGROUND Radioactive iodine (RAI) remnant ablation has been used to eliminate normal thyroid tissue and may also facilitate monitoring for persistent or recurrent thyroid carcinoma. The use of RAI for low-risk patients who we define as those under age 45 with stage I disease or over age 45 with stage I or II disease based on American Joint Committee on Cancer (AJCC) 6th edition, or low risk under the metastases, age, completeness of resection, invasion, size (MACIS) staging system (value <6) is controversial. In this extensive literature review, we sought to analyze the evidence for use of RAI treatment to improve mortality and survival and to reduce recurrence in patients of various stages and disease risk, particularly for those patients who are at low risk for recurrence and death from thyroid cancer. METHODS A MEDLINE search was conducted for studies published between January 1966 and April 2008 that compared the effectiveness of administering versus not administering RAI for treatment of differentiated thyroid cancer (DTC). Studies were grouped A through D based on their methodological rigor (best to worst). An analysis, focused on group A studies, was performed to determine whether treatment with RAI for DTC results in decreased recurrences and improved survival rates. RESULTS The majority of studies did not find a statistically significant improvement in mortality or disease-specific survival in those low-risk patients treated with RAI, whereas improved survival was confirmed for high-risk (AJCC stages III and IV) patients. Evidence for RAI decreasing recurrence was mixed with half of the studies showing a significant relationship and half showing no relationship. CONCLUSIONS We propose a management guideline based on a patients risk-very low, low, moderate, and high-for clinicians to use when delineating those patients who should undergo RAI treatment for initial postoperative management of DTC. A majority of very low-risk and low-risk patients, as well as select cases of patients with moderate risk do not demonstrate survival or disease-free survival benefit from postoperative RAI treatment, and therefore we recommend against postoperative RAI in these cases.

Measuring quality of care in patients with multiple clinical conditions: summary of a conference conducted by the Society of General Internal Medicine

Performance measurement has been widely advocated as a means to improve health care delivery and, ultimately, clinical outcomes. However, the evidence supporting the value of using the same quality measures designed for patients with a single clinical condition in patients with multiple conditions is weak. If clinically complex patients, defined here as patients with multiple clinical conditions, present greater challenges to achieving quality goals, providers may shun them or ignore important, but unmeasured, clinical issues. This paper summarizes the proceedings of a conference addressing the challenge of measuring quality of care in the patient with multiple clinical conditions with the goal of informing the implementation of quality measurement systems and future research programs on this topic. The conference had three main areas of discussion. First, the potential problems caused by applying current quality standards to patients with multiple conditions were examined. Second, the advantages and disadvantages of three strategies to improve quality measurement in clinically complex patients were evaluated: excluding certain clinically complex patients from a given standard, relaxing the performance target, and assigning a greater weight to some measures based on the expected clinical benefit or difficulty of reaching the performance target. Third, the strengths and weaknesses of potential novel measures such change in functional status were considered. The group concurred that, because clinically complex patients present a threat to the implementation of quality measures, high priority must be assigned to a research agenda on this topic. This research should evaluate the impact of quality measurement on these patients and expand the range of quality measures relevant to the care of clinically complex patients.

Quality Indicators for Hospitalization and Surgery in Vulnerable Elders

Hospitalization presents unique challenges in older people. Older patients may be more likely to suffer from comorbid illness or have diminished physiological reserves that impair their ability to maintain homeostasis in the context of acute illness. A variety of geriatric syndromes, such as dementia, delirium, and gait disturbance, are more common in older patients admitted to the hospital than in younger patients. In addition, vulnerable elders (VEs) may develop nosocomial or hospital-acquired pneumonia as an iatrogenic complication of hospitalization. Likewise, the risks of complications after surgery are also generally greater for elderly patients, primarily because of the frequency and severity of comorbid illnesses. In this article, quality indicators (QIs) for the general medical care of hospitalized VEs are presented, with a focus on elderly patients with pneumonia and those undergoing major surgery. For each indicator, the available supporting data are reviewed.

National Sleep Foundation's sleep quality recommendations: first report

Objectives: To provide evidence‐based recommendations and guidance to the public regarding indicators of good sleep quality across the life‐span. Methods: The National Sleep Foundation assembled a panel of experts from the sleep community and representatives appointed by stakeholder organizations (Sleep Quality Consensus Panel). A systematic literature review identified 277 studies meeting inclusion criteria. Abstracts and full‐text articles were provided to the panelists for review and discussion. A modified Delphi RAND/UCLA Appropriateness Method with 3 rounds of voting was used to determine agreement. Results: For most of the sleep continuity variables (sleep latency, number of awakenings >5 minutes, wake after sleep onset, and sleep efficiency), the panel members agreed that these measures were appropriate indicators of good sleep quality across the life‐span. However, overall, there was less or no consensus regarding sleep architecture or nap‐related variables as elements of good sleep quality. Conclusions: There is consensus among experts regarding some indicators of sleep quality among otherwise healthy individuals. Education and public health initiatives regarding good sleep quality will require sustained and collaborative efforts from multiple stakeholders. Future research should explore how sleep architecture and naps relate to sleep quality. Implications and limitations of the consensus recommendations are discussed.

An Evaluation of the Veterans Health Administration’s Clinical Reminders System: A National Survey of Generalists

BACKGROUNDThe Veterans Health Administration (VHA) is a leader in developing computerized clinical reminders (CCRs). Primary care physicians’ (PCPs) evaluation of VHA CCRs could influence their future development and use within and outside the VHA.OBJECTIVESurvey PCPs about usefulness and usability of VHA CCRs.DESIGN AND PARTICIPANTSIn a national survey, VHA PCPs rated on a 7-point scale usefulness and usability of VHA CCRs, and standardized scales (0–100) were constructed. A hierarchical linear mixed (HLM) model predicted physician- and facility-level variables associated with more positive global assessment of CCRs.RESULTSFour hundred sixty-one PCPs participated (response rate, 69%). Scale Cronbach’s alpha ranged from 0.62 to 0.82. Perceptions of VHA CCRs were primarily in the midrange, where higher ratings indicate more favorable attitudes (weighted standardized median, IQR): global assessment (50, 28–61), clinical/situational specificity (29, 17–42), integration with workflow/workload (39, 17–50), training (50, 33–67), VHA’s management of CCR use (67, 50–83), design/interface (53, 40–67), perceived role in CCR use (67, 50–83), and self-efficacy (67, 57–78). In a HLM model, design/interface (p < .001), self-efficacy (p < .001), integration with workflow/workload (p < .001), and training (p < .001) were associated with more favorable global assessments of CCRs. Facilities in the west as compared to the south (p = .033), and physicians with academic affiliation (p = .045) had less favorable global assessment of CCRs.CONCLUSIONSOur systematic assessment of end-users’ perceptions of VHA CCRs suggests that CCRs need to be developed and implemented with a continual focus on improvement based on end-user feedback. Potential target areas include better integration into the primary care clinic workflow/workload.

Clinical Reminders: Why Don't they use them?

There are many potential benefits associated with the use of computerized clinical reminders for both health care providers and patients. Clinical reminders are designed to reduce the likelihood that an aspect of care will “fall though the cracks” during a busy exam, ensure that care is well-documented so that the range of health care providers interacting with each patient will have full access to the patient history, and increase standardization across patient exams. While most agree that the concept of clinical reminders is good, recent research indicates that some providers do not use clinical reminders when available (Demakis et al, 2000). This paper describes the qualitative portion of a survey study aimed at exploring the perceived facilitators and barriers to clinical reminder use within Veterans Administration health care facilities.

Cognitive Behavioral Therapy for Insomnia in Older Veterans Using Nonclinician Sleep Coaches: Randomized Controlled Trial

To test a new cognitive behavioral therapy for insomnia (CBT‐I) program designed for use by nonclinicians.

Quality Indicators for the Care of Hypertension in Vulnerable Elders

Providing high quality of care to older adults with hypertension is growing in importance because of improved survival of patients with hypertension into old age and a growing older population at risk for developing systolic hypertension. Hypertension, a condition associated with mortality and functional decline with age, affects 79% of those aged 80 and older. Despite improved treatment of hypertension in the general U.S. population, the older population with hypertension continues to have poorer blood pressure (BP) control than younger populations. This new proposed indicator set for the care of hypertension in vulnerable elders (VEs) reflects two new themes. The first is a shift in emphasis toward the treatment of systolic hypertension (SH), rather than diastolic, because of known risk associated with SH and downstream cardiovascular and mortality benefits of treating SH in older adults. The second addresses systolic BP (SBP) goals, including the goals of therapy for VEs and those in the oldest age groups, that account for individual values and preferences and expected benefits of antihypertensive medications in the context of overall prognosis, multiple morbidities, and risk of adverse drug events.

Report and Research Agenda of the American Geriatrics Society and National Institute on Aging Bedside-to-Bench Conference on Sleep, Circadian Rhythms, and Aging: New Avenues for Improving Brain Health, Physical Health, and Functioning

The American Geriatrics Society, with support from the National Institute on Aging and other funders, held its eighth Bedside‐to‐Bench research conference, entitled “Sleep, Circadian Rhythms, and Aging: New Avenues for Improving Brain Health, Physical Health and Functioning,” October 4 to 6, 2015, in Bethesda, Maryland. Part of a conference series addressing three common geriatric syndromes—delirium, sleep and circadian rhythm (SCR) disturbance, and voiding dysfunction—the series highlighted relationships and pertinent clinical and pathophysiological commonalities between these three geriatric syndromes. The conference provided a forum for discussing current sleep, circadian rhythm, and aging research; identifying gaps in knowledge; and developing a research agenda to inform future investigative efforts. The conference also promoted networking among developing researchers, leaders in the field of SCR and aging, and National Institutes of Health program personnel.