Juliessa M Pavon

Physical Performance and Subsequent Disability and Survival in Older Adults with Malignancy: Results from the Health, Aging and Body Composition Study

OBJECTIVES: To evaluate objective physical performance measures as predictors of survival and subsequent disability in older patients with cancer.

Parkinson's disease in women: a call for improved clinical studies and for comparative effectiveness research.

The incidence and prevalence of Parkinsons disease (PD) is expected to rise precipitously over the next several decades, as will the associated healthcare related costs. The epidemiology and disease manifestations of PD may differ when comparing women to men. Women are for example less likely to acquire PD, and in several studies have demonstrated a delayed onset of motor symptoms. Women, however, are more likely to experience PD-related complications that may lead to disability (e.g. depression and medication-associated dyskinesia). Further, there are purported differences in the treatment and treatment outcomes in PD men compared to women. Whether estrogen, other hormonal activity, or whether multiple factors underpin these findings remains unknown. Also unknown is whether estrogen itself may represent a therapeutic option for symptomatic PD treatment. This review summarizes what is known about gender differences in epidemiology, clinical features, treatment outcomes (medical and surgical/deep brain stimulation), and social impact among all available PD studies. We offer expert opinion regarding the shortcomings of the current evidence, and we propose a detailed list of studies that will help to clarify important gender related PD questions. Our hope is that this review will spark comparative effectiveness research into improving care and outcomes in women with PD.

Assisted Early Mobility for Hospitalized Older Veterans: Preliminary Data from the STRIDE Program

An important contributor to hospital‐associated disability is immobility during hospitalization. Preliminary results from STRIDE, a clinical demonstration program of supervised walking for older adults admitted to the hospital with medical illness, are reported. The STRIDE program consisted of a targeted gait and balance assessment by a physical therapist, followed by daily walks supervised by a recreation therapy assistant for the duration of the hospital stay. To examine program effectiveness, STRIDE participants (n = 92) were compared with individuals referred but not enrolled (because of refusal or because program was at capacity, n = 35). Median length of stay was 4.7 days for STRIDE participants and 5.7 days for individuals receiving usual care (P = .31). There was one inpatient fall in each group (not associated with a STRIDE walk). Overall, 92% of STRIDE participants were discharged to home (rather than a skilled nursing facility (SNF)) compared to 74% of individuals receiving usual care (P = .007). Thirty‐day emergency department visit rates and readmission rates were not significantly different between the two groups. STRIDE, a supervised walking program for hospitalized older adults, was feasible and safe, and program participants were less likely to be discharged to a SNF than a demographically similar comparison group. STRIDE is a promising interdisciplinary approach to promoting mobility and improving outcomes in hospitalized older adults.

Identifying risk of readmission in hospitalized elderly adults through inpatient medication exposure.

To use electronic health record (EHR) data to examine the association between inpatient medication exposure and risk of hospital readmission.

Effectiveness of Intermittent Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis in High-Risk Surgical Patients: A Systematic Review

BACKGROUND Thromboprophylaxis regimens include pharmacologic and mechanical options such as intermittent pneumatic compression devices (IPCDs). There are a wide variety of IPCDs available, but it is uncertain if they vary in effectiveness or ease of use. This is a systematic review of the comparative effectiveness of IPCDs for selected outcomes (mortality, venous thromboembolism [VTE], symptomatic or asymptomatic deep vein thrombosis, major bleeding, ease of use, and adherence) in postoperative surgical patients. METHODS We searched MEDLINE (via PubMed), Embase, CINAHL, and Cochrane CENTRAL from January 1, 1995, to October 30, 2014, for randomized controlled trials, as well as relevant observational studies on ease of use and adherence. RESULTS We identified 14 eligible randomized controlled trials (2633 subjects) and 3 eligible observational studies (1724 subjects); most were conducted in joint arthroplasty patients. Intermittent pneumatic compression devices were comparable to anticoagulation for major clinical outcomes (VTE: risk ratio, 1.39; 95% confidence interval, 0.73-2.64). Limited data suggest that concurrent use of anticoagulation with IPCD may lower VTE risk compared with anticoagulation alone, and that IPCD compared with anticoagulation may lower major bleeding risk. Subgroup analyses did not show significant differences by device location, mode of inflation, or risk of bias elements. There were no consistent associations between IPCDs and ease of use or adherence. CONCLUSIONS Intermittent pneumatic compression devices are appropriate for VTE thromboprophylaxis when used in accordance with current clinical guidelines. The current evidence base to guide selection of a specific device or type of device is limited.

Inpatient Mobility Measures As Useful Predictors of Discharge Destination in Hospitalized Older Adults

To the Editor: Postacute care skilled nursing facility (SNF) stays are frequent and costly for the more than 13.6 million older adults who are discharged annually from nonfederal U.S. hospitals. An important determinant of the need for postacute care in a SNF setting is an individual’s functional ability. Mobility status, a distinct aspect of functional ability, may be particularly useful in identifying hospitalized older adults who are likely to need posthospital SNF care. Mobility can be measured through observed performance-based or self-reported measures. Lacking from the literature is knowledge of which mobility measures in the inpatient setting are predictive of important hospital outcomes. The specific aim of this study was to determine whether performance-based and self-reported measures of mobility could distinguish individuals discharged to a SNF from those discharged home.

Poor adherence to risk stratification guidelines results in overuse of venous thromboembolism prophylaxis in hospitalized older adults

Venous thromboembolism (VTE) prophylaxis is an important consideration for every older adult admitted to the hospital1 but should not be prescribed to all patients. Use of anticoagulants (specifically low-molecular-weight heparin, low-dose unfractionated heparin, and fondaparinux) when not medically indicated may be harmful, especially for older adults who on average have more chronic conditions,1 take more potentially interacting medications,2 and have higher risks of bleeding.3 The American College of Chest Physicians (ACCP) Ninth Edition Guidelines for Antithrombotic Therapy and Prevention of Thrombosis explicitly recommend a risk-stratification approach using the Padua Prediction Score (PPS) to select those patients most likely to benefit from VTE prophylaxis.4,5 This study aimed to describe the use of risk stratification and pharmacologic VTE prophylaxis use in a population of medically ill, hospitalized older patients.

Resident learning across the full range of core competencies through a transitions of care curriculum.

ABSTRACT The authors developed a Transitions of Care (TOC) curriculum to teach and measure learner competence in performing TOC tasks for older adults. Internal medicine interns at an academic residency program received the curriculum, which consisted of experiential learning, self-study, and small group discussion. Interns completed retrospective pre/post surveys rating their confidence in performing five TOC tasks, qualitative open-ended survey questions, and a self-reflection essay. A subset of interns also completed follow-up assessments. For all five TOC tasks, the interns’ confidence improved following completion of the TOC curriculum. Self-confidence persisted for up to 3 months later for some but not all tasks. According to the qualitative responses, the TOC curriculum provided interns with learning experiences and skills integral to performing safe care transitions. The TOC curriculum and a mixed-method assessment approach effectively teaches and measures learner competency in TOC across all six Accreditation Council for Graduate Medical Education competency domains.

Automated versus Manual Data Extraction of the Padua Prediction Score for Venous Thromboembolism Risk in Hospitalized Older Adults

OBJECTIVE Venous thromboembolism (VTE) prophylaxis is an important consideration for hospitalized older adults, and the Padua Prediction Score (PPS) is a risk prediction tool used to prioritize patient selection. We developed an automated PPS (APPS) algorithm using electronic health record (EHR) data. This study examines the accuracy of APPS and its individual components versus manual data extraction. METHODS This is a retrospective cohort study of hospitalized general internal medicine patients, aged 70 and over. Fourteen clinical variables were collected to determine their PPS; APPS used EHR data exports from health system databases, and a trained abstractor performed manual chart abstractions. We calculated sensitivity and specificity of the APPS, using manual PPS as the gold standard for classifying risk category (low vs. high). We also examined performance characteristics of the APPS for individual variables. RESULTS PPS was calculated by both methods on 311 individuals. The mean PPS was 3.6 (standard deviation, 1.8) for manual abstraction and 2.8 (1.4) for APPS. In detecting patients at high risk for VTE, the sensitivity and specificity of the APPS algorithm were 46 and 94%, respectively. The sensitivity for APPS was poor (range: 6-34%) for detecting acute conditions (i.e., acute myocardial infarction), moderate (range: 52-74%) for chronic conditions (i.e., heart failure), and excellent (range: 94-98%) for conditions of obesity and restricted mobility. Specificity of the automated extraction method for each PPS variable was > 87%. CONCLUSION APPS as a stand-alone tool was suboptimal for classifying risk of VTE occurrence. The APPS accurately identified high risk patients (true positives), but lower scores were considered indeterminate.

Sensitivity of osteoporosis screening guidelines for eventual hip fracture in older male veterans

This study sought to determine whether guideline-recommended clinical criteria to select men for osteoporosis screening provide significantly better sensitivity than the osteoporotic screening tool (OST) among men who later went on to have a hip fracture, and whether the sensitivity differs by race. This retrospective observational study uses data from the Department of Veterans Affairs Austin Automation Center. We identified 825 male veterans with hip fractures from 2007 to 2009. Clinical risk factors used as screening selection criteria were abstracted from five accepted guidelines. Outpatient encounters were examined for each subject to determine whether they would have met screening selection criteria for each guideline in the 5 years before their hip fracture event. Sensitivities for each guideline were compared with the OST, using McNemars exact test. Sensitivities of Veterans Affairs Health Service Research and Development Services (VA HSR&D) and National Osteoporosis Foundation (NOF) guidelines were 77% and 82%, respectively, and were significantly better than the OST sensitivity of 72% (P<0.05). Sensitivities of American College of Physicians (ACP; 68%), VA Secretarys Letters (45%) and Center for Medicare and Medicaid Services (13%) were significantly worse than the OST sensitivity (P<0.001). The sensitivities of the VA HSR&D, ACP and NOF were significantly higher in Whites compared with non-Whites (76% vs 65%, P<0.01; 70% vs 58%, P<0.01; and 84% vs 70%, P<0.001, respectively). Only VA HSR&D and NOF clinical screening criteria are more sensitive than OST in identifying veterans who subsequently experience hip fractures, and these sensitivities vary by race.