Stuti Dang

Evaluating the Evidence Base for the Use of Home Telehealth Remote Monitoring in Elderly with Heart Failure

Information and communication technology offers promise for better coordination of care for patients with congestive heart failure (CHF). MEDLINE, EMBASE, and CINHAL databases were searched for evidence on remote monitoring of patients with heart failure (HF). The search was restricted to randomized controlled trials using either automated monitoring of signs and symptoms or automated physiologic monitoring. For this review, telephone-based monitoring of signs and symptoms was not considered remote monitoring. Studies were also excluded if they did not present outcomes related to healthcare utilization. Nine studies met selection criteria, with interventions that varied greatly. Four three-arm studies directly compared the effectiveness of two different interventions to usual care. Six of the nine studies suggested a 27%-40% reduction in overall admissions. Two two-arm studies demonstrated a 40%-46% reduction in HF-related admissions while two other three-arm studies showed similar trends; however, this was not statistically significant. Three of nine studies suggested a significant reduction in mortality (30%-67%) and three studies showed significant reduction in healthcare utilization costs. Two studies suggested a 53%-62% reduction in bed days of care. Two studies showed significant reduction in the number of Emergency Department visits. Three two-arm studies and one three-arm study demonstrated significant overall improvement in outcomes with use of telemonitoring. Available data suggest that telemonitoring is a promising strategy. More data are needed to determine the ideal patient population, technology, and parameters, frequency and duration of telemonitoring, and the exact combination of case management and close monitoring that would assure consistent and improved outcomes with cost reductions in HF.

Care Management’s Challenges and Opportunities to Reduce the Rapid Rehospitalization of Frail Community-Dwelling Older Adults

Community-based frail older adults, burdened with complex medical and social needs, are at great risk for preventable rapid rehospitalizations. Although federal and state regulations are in place to address the care transitions between the hospital and nursing home, no such guidelines exist for the much larger population of community-dwelling frail older adults. Few studies have looked at interventions to prevent rehospitalizations in this large segment of the older adult population. Similarly, standardized disease management approaches that lower hospitalization rates in an independent adult population may not suffice for guiding the care of frail persons. Care management interventions currently face unique challenges in their attempt to improve the transitional care of community-dwelling older adults. However, impending national imperatives aimed at reducing potentially avoidable hospitalizations will soon demand and reward care management strategies that identify frail persons early in the discharge process and promote the sharing of critical information among patients, caregivers, and health care professionals. Opportunities to improve the quality and efficiency of care-related communications must focus on the effective blending of training and technology for improving communications vital to successful care transitions.

Care coordination and telemedicine improves glycaemic control in ethnically diverse veterans with diabetes

We conducted a pilot study of a care-coordination programme involving daily monitoring and education of elderly diabetic veterans from different racial/ethnic groups. A telephone-based, in-home messaging device was used for patient monitoring and education. Sixty-nine patients were enrolled in the study and HbA1c values were obtained both before and after the telemedicine intervention in 41 of them. The mean HbA1c before enrolment was 7.6% and the mean value 9 months later was 7.3% (P = 0.09). The greatest fall in HbA1c occurred in African-Americans (0.65%, P = 0.05). The total number of hospital admissions decreased from 31 pre-enrolment to 25 post-enrolment (P = 0.0002). Bed days of care decreased from 368 to 149 (P = 0.0002). Care coordination, facilitated by telemedicine, appeared to improve glycaemic control in veterans with diabetes from diverse ethnic backgrounds, particularly African-Americans. This may reduce health-care resource utilization.

Care coordination assisted by technology for multiethnic caregivers of persons with dementia: a pilot clinical demonstration project on caregiver burden and depression

We evaluated a care-coordination project assisted by a screen-phone to support and educate caregivers. A total of 113 caregivers of home-dwelling veterans with dementia were recruited to the study: 72 were white, 32 were African American and nine were Hispanic. Caregivers were assessed for burden, depression, coping, quality of life, knowledge and satisfaction. None of the outcome measures changed significantly after 12 months. Forty care-recipient and caregiver dyads responded to the 12-month telephone satisfaction survey. The respondents were more satisfied with the care-coordination (90%) aspect of the programme than the education (77%) or the monitoring (50%). The pilot project suggests that care coordination aided by screen-phones may be a useful model for caregiver support in a managed-care setting. A systematic study is now required.

Telehealth-assisted care coordination of older veterans with type 2 diabetes lowers coronary heart disease risk despite clinical inertia.

BACKGROUND The purpose of this study was to determine the impact of a telehealth care coordination (T-Care) program on coronary heart disease (CHD) risk in older adults with type 2 diabetes (T2D). METHODS Forty-one patients with T2D, 68.7 (±8.9) years old, were enrolled in the T-Care program and followed up for 2 years. Data were collected on blood pressure (BP), lipids, and medications. CHD risk or Framingham risk score (FRS) was estimated by using the calculation for 10-year CHD risk based on the risk estimates derived from the experience of the Framingham Heart Study. Clinical inertia was defined as the lack of dose adjustment or new medication for BP or lipid management when appropriate, per standard-of-care guidelines. RESULTS After 2 years of T-Care intervention, significant reductions were demonstrated in FRS (23.4 ± 13.5 to 18.2 ± 10.4, P = 0.007), systolic BP (140 ± 22.7 to 128.2 ± 18.5 mm Hg, P = 0.05), and diastolic BP (74 ± 13.8 to 68.7 ± 13.9 mm Hg, P = 0.07), but not low-density lipoprotein (LDL) cholesterol (100.2 ± 30.1 to 91.2 ± 26.6 mg/dL, P = 0.7). Clinical inertia for lipids was found in 17.1% of our patients; only those without clinical inertia showed significant reduction in the LDL cholesterol component of the FRS. In contrast, clinical inertia for BP was documented in 12.2% of our patients, but reduction in the BP component of the FRS was independent of the presence of clinical inertia. CONCLUSION Participation in a T-Care program may lead to significantly reduced CHD risk among older patients with T2D, despite clinical inertia.

Financial effect of a hospital outpatient senior clinic on an academic medical center

OBJECTIVES: To estimate the billed charges generated for the university hospital (UH) by patients seen in a UH outpatient senior clinic over a 6‐month period. To estimate the average billed charges per geriatric patient generated for the UH over the same 6‐month period.

The stroke caregiving trajectory in relation to caregiver depressive symptoms, burden, and intervention outcomes

Abstract Background: Caregiver depression and burden have a detrimental effect on stroke survivors’ rehabilitation and are contributors to stroke survivors’ hospital readmission and institutionalization. The stroke caregiving trajectory is unique compared to other illnesses, and the effect of length of caregiving on stroke caregiver outcomes is poorly understood. Interventions can improve caregiver outcomes, but the optimal timing of these interventions is unclear. Objectives: We sought to determine the relationship between: (1) length of caregiving and stroke caregiver depressive symptoms and burden, and (2) length of caregiving and amount of change in depressive symptoms and burden following the Resources and Education for Stroke Caregivers’ Understanding and Empowerment (RESCUE) intervention – an online and telephone problem-solving, education, and support intervention. Methods: We analyzed retrospective data collected from 72 stroke caregivers who participated in the RESCUE intervention. Outcomes were caregiver depressive symptoms and burden. Data were analyzed using mixed-effects regression analysis. Results: Baseline depressive symptoms and burden were both negatively related to length of caregiving (p < 0.05). We found significant improvement in caregiver depressive symptoms and burden following an intervention. The interaction between changes in outcomes and length of caregiving was not significant for either depressive symptoms (p = 0.26) or burden (p = 0.10). Conclusions: This study contributes to the understanding of the relationship between length of caregiving and depression, burden, and intervention outcomes. Clinicians should recognize that the stroke caregiving trajectory can be nonlinear. Routine and repeated clinical assessment of caregiver well-being is needed, along with implementation of interventions when necessary, regardless of how much time has passed since the stroke.

Diabetes Treatment in the Elderly: Incorporating Geriatrics, Technology, and Functional Medicine

Purpose of ReviewThe current approach to diabetes in the elderly incorporates components from the comprehensive geriatric approach. The most updated guidelines from the American Diabetes Association reflect influence from the consensus made in 2012 with the American Geriatrics Society. Notably, the framework included the evaluation for geriatric syndromes (falls and urinary incontinence), functional and cognitive abilities. The goal for this review is to provide an updated summary of treatment strategies for community-dwelling older adults. We identified the need to expand our approach by addressing innovative approaches and scientific concepts from telemedicine, functional medicine, and geriatrics.Recent FindingsFindings on cardiovascular protection with sodium-glucose co-transporter 2 inhibitors (SGLT-2i) and some glucagon-like peptide 1 receptor agonists (GLP-1RA) support their use for older patients with diabetes. However, careful consideration for agent selection must incorporate the presence of geriatric issues, such as geriatric syndromes, or functional and cognitive decline, as they could increase the risk and impact adverse reactions. Telemedicine interventions can improve communication and connection between older patients and their providers, and improve glycemic control. Functional medicine concepts can offer additional adjuvant strategies to support the therapeutic interventions and management of diabetes in the elderly.SummaryA systematic review confirmed the efficacy and safety of metformin as first-line therapy of type 2 diabetes in the older adult, but multiple reports highlighted the risk for vitamin B12 deficiency. Randomized controlled trials showed the efficacy and safety of antihyperglycemic agents in the elderly, including some with longer duration and lesser risk for hypoglycemia. Randomized clinical trials showed cardiovascular protection with SGLT-2i (empagliflozin, canagliflozin) and GLP-1RA (liraglutide, semaglutide). The most current guidelines recommend addressing for geriatric syndromes, physical and cognitive function in the elderly, in order to individualize targets and therapeutic strategies. Clinicians managing diabetes in the elderly can play a major role for the early detection and evaluation of geriatric issues in their patients. Telemedicine interventions improve glycemic control, and certain functional medicine strategies could be adjuvant interventions to reduce inflammation and stress, but more studies focused on the elderly population are needed.

Validation of an automatically generated screening score for frailty: the care assessment need (CAN) score.

BackgroundFrailty is a state of vulnerability to stressors that is prevalent in older adults and is associated with higher morbidity, mortality and healthcare utilization. Multiple instruments are used to measure frailty; most are time-consuming. The Care Assessment Need (CAN) score is automatically generated from electronic health record data using a statistical model. The methodology for calculation of the CAN score is consistent with the deficit accumulation model of frailty. At a 95 percentile, the CAN score is a predictor of hospitalization and mortality in Veteran populations. The purpose of this study was to validate the CAN score as a screening tool for frailty in primary care.MethodsThis is a cross-sectional, validation study compared the CAN score with a 40-item Frailty Index reference standard based on a comprehensive geriatric assessment. We included community-dwelling male patients over age 65 from an outpatient geriatric medicine clinic. We calculated the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of the CAN score.Results184 patients over age 65 were included in the study: 97.3% male, 64.2% White, 80.9% non-Hispanic. The CGA-based Frailty Index defined 14.1% as robust, 53.3% as prefrail and 32.6% as frail. For the frail, statistical analysis demonstrated that a CAN score of 55 provides sensitivity, specificity, PPV and NPV of 91.67, 40.32, 42.64 and 90.91% respectively whereas at a score of 95 the sensitivity, specificity, PPV and NPV were 43.33, 88.81, 63.41, 77.78% respectively. Area under the receiver operating characteristics curve was 0.736 (95% CI = .661–.811).ConclusionCAN score is a potential screening tool for frailty among older adults; it is generated automatically and provides acceptable diagnostic accuracy. Hence, the CAN score may be a useful tool to primary care providers for detection of frailty in their patient panels.

Association of the CAN score with the FRAIL scale in community dwelling older adults

BackgroundFrailty is a state of vulnerability to stressors which results in higher morbidity, mortality and healthcare utilization. The FRAIL scale is used as a validated screening for frailty. The Care Assessment Need (CAN) score is automatically generated from electronic health record data using a statistical model that includes data elements similar to the deficit accumulation model for frailty and predicts risk for hospitalization and/or mortality.AimTo determine the correlation of the CAN score with the FRAIL scale.MethodsA cross-sectional study of 503 community-dwelling older adults. We compared the FRAIL scale with the CAN score.ResultsThe CAN score was significantly different between robust, prefrail and frail. Post hoc analysis revealed significant increases in scores from robust to prefrail and frail groups, in that order. The CAN score and FRAIL scale showed a correlation.ConclusionsThe CAN score show a moderate positive association with the FRAIL scale.