Patricia P. Barry

Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians

This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.

Electroconvulsive Therapy in Octogenarians

Medical records of 81 older patients (65 years of age and over) who underwent electroconvulsive therapy (ECT) at a university‐affiliated private geriatric hospital were reviewed to evaluate the safety and efficacy of this treatment for depression in the “young‐old” (65 to 80 years) compared with the “old‐old” age group (over 80 years), a group that has not yet been adequately studied.

Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians.

Venous thromboembolism is a common condition affecting 7.1 persons per 10,000 person-years among community residents. Incidence rates for venous thromboembolism are higher in men, African-Americans, and increase substantially with age. It is critical to treat deep venous thrombosis at an early stage to avoid development of further complications, such as pulmonary embolism or recurrent deep venous thrombosis. The target audience for this guideline is all clinicians caring for patients who have been given a diagnosis of deep venous thrombosis or pulmonary embolism. The target patient population is patients receiving a diagnosis of pulmonary embolism or lower-extremity deep venous thrombosis.

Practicing Physician Education in Geriatrics: Lessons Learned from a Train‐the‐Trainer Model

Evidence of poor performance in the evaluation and management of common geriatric conditions suggests the need for changing physician behavior in these areas. Traditional lecture‐style continuing medical education (CME) has not been shown to be effective. Expert faculty initially trained 60 nonexpert peer educators to conduct small‐group, learner‐centered CME using tool kits on memory loss, incontinence, and depression. Peer educators presented 109 community‐based sessions to 1,309 medical practitioners. Surveys were administered to community participants immediately and 6 months after a session. Evidence of effectiveness included statistically significant increases in self‐reported knowledge, attitudes, and office‐based practices on the target topics at the time of training and at the 6‐month follow‐up (P<.001) and two‐thirds of respondents reporting continued use of three or more tools at 6 months. Participants reported that the interactive presentation aided their understanding of and ability to use the tool kits more than an off‐the‐shelf review (mean rating±standard deviation 4.1±0.71, with 1=not at all and 5=significantly). After the formal evaluation period, additional information about the project dynamics and tool kits was obtained through a small interview sample and an on‐line survey, respectively. Receiving copies of the tool kits was an important factor in enabling educators to offer sessions. Barriers to offering sessions included finding time, an audience, and space. Findings suggest that modest positive changes in practice in relation to common geriatric problems can be achieved through peer‐led, community‐based sessions using principles of knowledge translation and evidence‐based tool kits with materials for providers and patients.

Geriatric clinical training in medical schools

The primary purpose of geriatric training in medical school is to improve the care of the elderly by practitioners in every specialty, by increasing their knowledge base and fostering interest in older patients. A secondary goal is to interest some students in geriatrics as a career. For > 10 years, leaders in medicine and medical education have strongly recommended clinical geriatric training for medical students, but only a few programs have been implemented. Geriatrics educational experiences must be required; otherwise, not enough medical students will elect to take these courses. Although we still do not know which model best provides this experience, evaluations of existing programs suggest that geriatrics can be taught in both long-term care and acute settings, involving well-designed curriculum and interested faculty. More studies are needed, but exposure to well elderly and community-based programs may also improve attitudes toward the elderly and thereby further improve their medical care.

Outpatient Comprehensive Geriatric Assessment: An Intervention Whose Time Has Come, or Has It?

n 1988, the National Institutes of Health sponsored a I Consensus Development Conference on Geriatric Assessment Methods for Clinical Decision-making. The Consensus Statement issued by the conference noted that the goals of assessment are to improve diagnostic accuracy, guide the selection of interventions to restore or preserve health, recommend an optimal environment, predict outcomes, and monitor clinical change.’ These are often interdependent so that diagnostic accuracy leads to appropriate interventions and better use of available services, resulting in improved level of function and optimal placcment. In particular, it is important to target assessment to those persons most likely to benefit, especially those who are frail, a t critical transition points, or in declining health or function. In addition, it is essential to link assessment with care management and follow-up services in order to implement the recommendations. Geriatric assessment has since been implemented in inpatient units, outpatient and home care programs, and longterm care facilities. Well-designed studies have demonstrated the value of assessment in improving diagnostic and therapeutic outcomes in some (but not all) settings, usually involving assessment by multidisciplinary teams and follow-up case management. A 1993 meta-analysis of 28 controlled trials of five types of geriatric assessment concluded that programs linking evaluation with strong long-term management are effective for improving survival and function in older persons.’ Ten years after the consensus conference, it is worth noting that the issues of targeting and follow-up continue to be critical to the success of geriatric assessment programs. In this issue, Reuben and colleagues have conducted a study of outpatient comprehensivc geriatric assessment in concert with an intervention designed to increase both physician and patient adherence to recommendation^.^ It draws on the lessons learned from more than a decade of research. The clear strengths of their work are the use of the clinical trial study design and a targeting strategy that yielded a sample of patients at risk for functional decline, depression, urinary incontinence, and/or falls. Furthermore, they developed and implemented successfully an intervention that addressed both physician and patient behavior. Indeed, this latter strategy is the most innovative and refreshing aspect of their study. It reflects the recognition that engaging both parties in the doctor-patient relationship is necessary to achieve goals in the setting of chronic disease care.4 In addition to careful attention to study design, the manner in which Reuben’s group carried out their study is impressive. They successfully recruitcd and randomized older persons, delivered the intervention to virtually all of the physicians and older persons in the experimental group, and achieved 15-month follow-up for 98% of recruited subjects. Because of their careful attention to study design and implementation, the threats to validity in this study are few. Nonetheless, their report raises several important questions. First, what were the actual recommendations given to physicians and patients? An earlier report by the authors gives us some clues.’ In that preliminary work, among the recommendations given to physicians and patients, the largest categories were for the attention to general medical problems, including hypertension (28%), prevention issues (26%), and functional impairment/musculoskeletaI problems/falls (15%). Urinary incontinence (12%) and depression (8%) evaluation and treatment recommendations were less common. Although little information is provided regarding who adhered to which recommendations, physicians and patients implemented or adhered to about two-thirds of recommendations. The authors note that patients had the most difficulty adhering to lifestyle changes such as exercises, counseling, and smoking cessation. In the study reported in this issue of the Journal, adherence rates were similar.3 Assuming that the categories of recommendations and the prevalence of recommendations within categories were similar in the present study, we are not surprised that patient outcomes at 15 months were only modestly better in the experimental group than in the control group. For example, at 15 months, the treatment group’s PFIlO adjusted scores were, on average, about 5 points higher than those of the control group. For many clinicians, it may be difficult to understand a PFIlO score in clinical terms. For example, on average, patients with hypertension score about 6 points higher on the PFIlO than do patients with type 2 diabetes. Persons 75 ycars of age and older score about 16 points lower than persons aged 65 to 74.6

Why Elderly Patients Refuse Hospitalization

To identify important factors in the refusal of hospitalization by elderly patients, a study was conducted of 35 such “refusers” on the Home Medical Service (HMS) of University Hospital and a comparison group of 70 patients who accepted hospitalization. Data were collected from health care providers and patient records at entry and six weeks later. The two groups were compared on the basis of demographic factors, health care factors, medical condition, and outcomes. Reasons for refusal were most commonly related to a negative perception of the health care system or a passive acceptance of death. Refusers were significantly less ill than acceptors and did not change in health or functional status at follow‐up. The results suggest that refusal of hospitalization is most often related to interaction with the health care system and that less ill patients may have reasonable outcomes when treated at home.

Digitalis Use in a Retirement Community

Complex medical problems of older patients demand that particular care be taken with their use of digitalis, Although accounting for more than 5% of the top ten prescribed drugs in the United States, studies have suggested that digitalis use might be discontinued in some patients without harm. To assess the potential impact of these observations, a survey was conducted to evaluate the extent of digitalis use in a retirement community in Florida.

Current diagnosis of venous thromboembolism in primary care

This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.

Annals Journal Club: Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians

This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.