Susan E. Merel

Ten ways to improve the care of elderly patients in the hospital.

Hospitalists care for elderly patients daily, but few have specialized training in geriatric medicine. Elderly patients, and in particular the very old and the frail elderly, are at high risk of functional decline and iatrogenic complications during hospitalization. Other challenges in caring for this patient population include dosing medications safely, preventing delirium and accidental falls, and providing adequate pain control. Ways to improve the care of the hospitalized elderly patient include the following: screening for geriatric syndromes such as delirium, assessing functional status and maintaining mobility, and implementation of interventions that have been shown to prevent delirium, accidental falls, and acute functional decline in the hospital. This article addresses these issues with 10 evidence-based pearls developed to help hospitalists provide optimal care for this expanding population.

Palliative care in advanced dementia.

Because neurodegenerative dementias are progressive and ultimately fatal, a palliative approach focusing on comfort, quality of life, and family support can have benefits for patients, families, and the health system. Elements of a palliative approach include discussion of prognosis and goals of care, completion of advance directives, and a thoughtful approach to common complications of advanced dementia. Physicians caring for patients with dementia should formulate a plan for end-of-life care in partnership with patients, families, and caregivers, and be prepared to manage common symptoms at the end of life in dementia, including pain and delirium.

Common Drug Side Effects and Drug‐Drug Interactions in Elderly Adults in Primary Care

Prescribing medications, recognizing and managing medication side effects and drug interactions, and avoiding polypharmacy are all essential skills in the care of older adults in primary care. Important side effects of medications commonly prescribed in older adults (statins, proton pump inhibitors, trimethoprim‐sulfamethoxazole and fluoroquinolone antibiotics, zolpidem, nonsteroidal antiinflammatory drugs, selective serotonin reuptake inhibitors, dipeptidyl peptidase 4 inhibitors) were reviewed. Important drug interactions with four agents or classes (statins, warfarin, factor Xa inhibitors, and calcium channel blockers) are discussed.

Geriatricians and Hospitalists: Opportunities for Partnership

One of the most important recent changes in U.S. health care is the rise in the fraction of hospitalized patients cared for by hospitalists. At the inception of the hospitalist movement, leaders predicted a profound effect on academic medical centers. They also predicted that hospitalists would be able to deliver more-efficient, ‘‘high value’’ care, with value defined as the quality of care divided by its cost. The first prediction has come true, with growing hospitalist groups at most major academic medical centers and academic hospitalists becoming leaders in quality improvement. The question remains what the effect has been on the overall quality of care provided to older patients. One large retrospective cohort study of 76,926 patients aged 18 and older used multivariable models to compare length of stay (LOS), rate of death, and costs of patients cared for by hospitalists, family physicians, and general internists. Hospitalists in this study were defined according to physician specialty codes. Patients cared for by hospitalists had a slightly shorter hospital stay (adjusted difference of 0.4 days) than those cared for by general internists and family physicians. Costs were very modestly lower for those cared for by hospitalists than for those cared for by general internists, but there was no significant difference in costs between those cared for by hospitalists and family physicians. Rates of death and of 14-day readmission were similar. A plethora of small observational studies have largely had similar findings, with patients being cared for by hospitalists having modest but statistically significantly shorter LOS, although many of these are small, singleinstitution studies and had few hospitalists caring for all of the patients in the hospitalist arm. Data from the Multicenter Hospitalist (MCH) Trial, a prospective multicenter observational study of the effect of hospitalist care at academic medical centers, have not indicated differences in LOS between patients cared for by hospitalists and nonhospitalists. For example, a recent analysis of 450 patients with upper gastrointestinal hemorrhage from the MCH Trial showed similar mean LOS for patients cared for by hospitalists and nonhospitalists and higher costs for patients cared for by hospitalists. Similarly, data from the MCH Trial did not show any significant differences in LOS or costs between patients with decompensated heart failure cared for by hospitalists and nonhospitalists. Even if we accept that hospitalists reduce LOS modestly, is that a clinically significant finding, and what are the implications for elderly patients? Kuo and colleagues have previously reported on the growth in the care of older adults by hospitalists, but few studies have focused on outcomes of hospitalist care in the elderly population. One small observational study at a community teaching hospital showed statistically significantly shorter LOS and lower total costs that were most pronounced in patients aged 65 and older. There have been a few studies of the effect of hospitalist management or comanagement of elderly patients with hip fractures, with one historical cohort study showing significantly shorter LOS (10.6 vs 8.4 days) in patients with hip fractures comanaged by hospitalists, with no difference in inpatient deaths, 30-day readmission rates, or 1-year mortality. Why has there been so little research on the effect of hospitalists on elderly patients? Hospital medicine remains a popular career choice for young internists, for many reasons, including the ability to take care of acutely ill patients, the ability to engage in quality improvement projects, and work–life balance, but it is probably safe to say that few hospitalists specifically choose the field for the opportunity to care for older adults and target research and quality improvement initiatives toward that population. Few hospitalists have special training in geriatric medicine, and few hospitalist groups have programs addressing the needs of elderly patients, even though hospitalists care for many elderly patients and may even care for patients in skilled nursing facilities. Geriatricians, with a few notable exceptions, have been largely absent from the debate over the merits of the hospitalist system. In this issue of the Journal of the American Geriatrics Society, Kuo and Goodwin report results of an ambitious study to understand the health services implications of nationwide hospital care of Medicare-eligible persons by hospitalists and nonhospitalists. Because several studies have shown shorter LOS associated with hospitalist care, the authors further attempt to understand various patient and hospital characteristics that may or may not be associated with this shorter LOS and whether this phenomenon is changing over time. This is a retrospective cohort study using a 5% national sample of Medicare beneficiaries, winnowed down to approximately 300,000 subjects for the characteristics analysis and approximately 2 million for the trend analysis. The latter sample is approximately half of all hospitalizations in the 5% sample. They employ elaborate and appropriate multivariable methods to control for a large number of variables and interaction terms, using a very large sample size to do so. They found that the adjusted LOS was 0.36 days shorter in patients cared for by hospitalists, a finding similar to a previous study. Kuo and Goodwin also found a greater difference in LOS in the oldest patients, with a difference of 0.63 days (95% confidence DOI: 10.1111/j.1532-5415.2010.03009.x

A Cross-Sectional Analysis of Publication Types in Quality Improvement Journals.

Despite widespread engagement in quality improvement activities, little is known about the designs of studies currently published in quality improvement journals. This study’s goal is to establish the prevalence of the types of research conducted in articles published in journals dedicated to quality improvement. A cross-sectional analysis was performed of 145 research articles published in 11 quality improvement journals in 2011. The majority of study designs were considered pre-experimental (95%), with a small percentage of quasi-experimental and experimental designs. Of the studies that reported the results of an intervention (n = 60), the most common research designs were pre–post studies (33%) and case studies (25%). There were few randomized controlled trials or quasi-experimental study designs (12% of intervention studies). These results suggest that there are opportunities for increased use of quasi-experimental study designs.

How to Teach Students on an Inpatient Clerkship

The inpatient clerkship is a critical time in the development of a medical student as they transition from student to clinician. The attending physician’s approach should be learner centered, emphasizing clinical immersion and autonomy, while still preserving safe patient care. Practices which maximize student learning include reviewing goals and expectations with the student early on, skillful use of the Socratic method, and providing frequent actionable feedback.

Toward Improving the Care of Older Adults

In this era of evidence-based medicine, the practice of geriatric medicine stands out as an area whereby guidelines are often not easily applied. Sometimes this is due to a lack of evidence because clinical trials only rarely include frail, medically complex, or very old persons. Other times, evidence pertinent to the patient’s issue at hand is available, but the application is complicated due to guidelines that may be overlapping or conflicting and may not match the care preferences of an older adult with multiple medical and psychosocial problems. Following guidelines designed for younger adults can even lead to harm in the elderly, for example, when strict blood pressure control contributes to falls. The aging of the Baby Boomers creates the imperative that all generalists be prepared for the challenges inherent in caring for older adults. We must be prepared to move past simple application of guidelines to an approach to the older patient that minimizes disability and maximizes quality of life. This issue ofMedical Clinics of North America considers important issues in the care of older adults with a focus on providing approaches to optimizing care of elderly persons with common and challenging conditions. Geriatricians are taught a syndromesbased, holistic approach to the patient encounter that strives to reduce disability and align care with the patient’s social situation and goals. This conceptual framework is essential in developing an approach to the care of the elderly patient. Authors review important aspects of this approach in articles about geriatric syndromes and assessment, cancer screening in older adults, and polypharmacy and rational prescribing. Tools to help assess prognosis, promote discussion of patient care preferences, and complete advance directives are provided.

Geriatricians and hospitalists

One of the most important recent changes in U.S. health care is the rise in the fraction of hospitalized patients cared for by hospitalists. At the inception of the hospitalist movement, leaders predicted a profound effect on academic medical centers. They also predicted that hospitalists would be able to deliver more-efficient, ‘‘high value’’ care, with value defined as the quality of care divided by its cost. The first prediction has come true, with growing hospitalist groups at most major academic medical centers and academic hospitalists becoming leaders in quality improvement. The question remains what the effect has been on the overall quality of care provided to older patients. One large retrospective cohort study of 76,926 patients aged 18 and older used multivariable models to compare length of stay (LOS), rate of death, and costs of patients cared for by hospitalists, family physicians, and general internists. Hospitalists in this study were defined according to physician specialty codes. Patients cared for by hospitalists had a slightly shorter hospital stay (adjusted difference of 0.4 days) than those cared for by general internists and family physicians. Costs were very modestly lower for those cared for by hospitalists than for those cared for by general internists, but there was no significant difference in costs between those cared for by hospitalists and family physicians. Rates of death and of 14-day readmission were similar. A plethora of small observational studies have largely had similar findings, with patients being cared for by hospitalists having modest but statistically significantly shorter LOS, although many of these are small, singleinstitution studies and had few hospitalists caring for all of the patients in the hospitalist arm. Data from the Multicenter Hospitalist (MCH) Trial, a prospective multicenter observational study of the effect of hospitalist care at academic medical centers, have not indicated differences in LOS between patients cared for by hospitalists and nonhospitalists. For example, a recent analysis of 450 patients with upper gastrointestinal hemorrhage from the MCH Trial showed similar mean LOS for patients cared for by hospitalists and nonhospitalists and higher costs for patients cared for by hospitalists. Similarly, data from the MCH Trial did not show any significant differences in LOS or costs between patients with decompensated heart failure cared for by hospitalists and nonhospitalists. Even if we accept that hospitalists reduce LOS modestly, is that a clinically significant finding, and what are the implications for elderly patients? Kuo and colleagues have previously reported on the growth in the care of older adults by hospitalists, but few studies have focused on outcomes of hospitalist care in the elderly population. One small observational study at a community teaching hospital showed statistically significantly shorter LOS and lower total costs that were most pronounced in patients aged 65 and older. There have been a few studies of the effect of hospitalist management or comanagement of elderly patients with hip fractures, with one historical cohort study showing significantly shorter LOS (10.6 vs 8.4 days) in patients with hip fractures comanaged by hospitalists, with no difference in inpatient deaths, 30-day readmission rates, or 1-year mortality. Why has there been so little research on the effect of hospitalists on elderly patients? Hospital medicine remains a popular career choice for young internists, for many reasons, including the ability to take care of acutely ill patients, the ability to engage in quality improvement projects, and work–life balance, but it is probably safe to say that few hospitalists specifically choose the field for the opportunity to care for older adults and target research and quality improvement initiatives toward that population. Few hospitalists have special training in geriatric medicine, and few hospitalist groups have programs addressing the needs of elderly patients, even though hospitalists care for many elderly patients and may even care for patients in skilled nursing facilities. Geriatricians, with a few notable exceptions, have been largely absent from the debate over the merits of the hospitalist system. In this issue of the Journal of the American Geriatrics Society, Kuo and Goodwin report results of an ambitious study to understand the health services implications of nationwide hospital care of Medicare-eligible persons by hospitalists and nonhospitalists. Because several studies have shown shorter LOS associated with hospitalist care, the authors further attempt to understand various patient and hospital characteristics that may or may not be associated with this shorter LOS and whether this phenomenon is changing over time. This is a retrospective cohort study using a 5% national sample of Medicare beneficiaries, winnowed down to approximately 300,000 subjects for the characteristics analysis and approximately 2 million for the trend analysis. The latter sample is approximately half of all hospitalizations in the 5% sample. They employ elaborate and appropriate multivariable methods to control for a large number of variables and interaction terms, using a very large sample size to do so. They found that the adjusted LOS was 0.36 days shorter in patients cared for by hospitalists, a finding similar to a previous study. Kuo and Goodwin also found a greater difference in LOS in the oldest patients, with a difference of 0.63 days (95% confidence DOI: 10.1111/j.1532-5415.2010.03009.x

Geriatricians and Hospitalists: Opportunities for Partnership: EDITORIAL

One of the most important recent changes in U.S. health care is the rise in the fraction of hospitalized patients cared for by hospitalists. At the inception of the hospitalist movement, leaders predicted a profound effect on academic medical centers. They also predicted that hospitalists would be able to deliver more-efficient, ‘‘high value’’ care, with value defined as the quality of care divided by its cost. The first prediction has come true, with growing hospitalist groups at most major academic medical centers and academic hospitalists becoming leaders in quality improvement. The question remains what the effect has been on the overall quality of care provided to older patients. One large retrospective cohort study of 76,926 patients aged 18 and older used multivariable models to compare length of stay (LOS), rate of death, and costs of patients cared for by hospitalists, family physicians, and general internists. Hospitalists in this study were defined according to physician specialty codes. Patients cared for by hospitalists had a slightly shorter hospital stay (adjusted difference of 0.4 days) than those cared for by general internists and family physicians. Costs were very modestly lower for those cared for by hospitalists than for those cared for by general internists, but there was no significant difference in costs between those cared for by hospitalists and family physicians. Rates of death and of 14-day readmission were similar. A plethora of small observational studies have largely had similar findings, with patients being cared for by hospitalists having modest but statistically significantly shorter LOS, although many of these are small, singleinstitution studies and had few hospitalists caring for all of the patients in the hospitalist arm. Data from the Multicenter Hospitalist (MCH) Trial, a prospective multicenter observational study of the effect of hospitalist care at academic medical centers, have not indicated differences in LOS between patients cared for by hospitalists and nonhospitalists. For example, a recent analysis of 450 patients with upper gastrointestinal hemorrhage from the MCH Trial showed similar mean LOS for patients cared for by hospitalists and nonhospitalists and higher costs for patients cared for by hospitalists. Similarly, data from the MCH Trial did not show any significant differences in LOS or costs between patients with decompensated heart failure cared for by hospitalists and nonhospitalists. Even if we accept that hospitalists reduce LOS modestly, is that a clinically significant finding, and what are the implications for elderly patients? Kuo and colleagues have previously reported on the growth in the care of older adults by hospitalists, but few studies have focused on outcomes of hospitalist care in the elderly population. One small observational study at a community teaching hospital showed statistically significantly shorter LOS and lower total costs that were most pronounced in patients aged 65 and older. There have been a few studies of the effect of hospitalist management or comanagement of elderly patients with hip fractures, with one historical cohort study showing significantly shorter LOS (10.6 vs 8.4 days) in patients with hip fractures comanaged by hospitalists, with no difference in inpatient deaths, 30-day readmission rates, or 1-year mortality. Why has there been so little research on the effect of hospitalists on elderly patients? Hospital medicine remains a popular career choice for young internists, for many reasons, including the ability to take care of acutely ill patients, the ability to engage in quality improvement projects, and work–life balance, but it is probably safe to say that few hospitalists specifically choose the field for the opportunity to care for older adults and target research and quality improvement initiatives toward that population. Few hospitalists have special training in geriatric medicine, and few hospitalist groups have programs addressing the needs of elderly patients, even though hospitalists care for many elderly patients and may even care for patients in skilled nursing facilities. Geriatricians, with a few notable exceptions, have been largely absent from the debate over the merits of the hospitalist system. In this issue of the Journal of the American Geriatrics Society, Kuo and Goodwin report results of an ambitious study to understand the health services implications of nationwide hospital care of Medicare-eligible persons by hospitalists and nonhospitalists. Because several studies have shown shorter LOS associated with hospitalist care, the authors further attempt to understand various patient and hospital characteristics that may or may not be associated with this shorter LOS and whether this phenomenon is changing over time. This is a retrospective cohort study using a 5% national sample of Medicare beneficiaries, winnowed down to approximately 300,000 subjects for the characteristics analysis and approximately 2 million for the trend analysis. The latter sample is approximately half of all hospitalizations in the 5% sample. They employ elaborate and appropriate multivariable methods to control for a large number of variables and interaction terms, using a very large sample size to do so. They found that the adjusted LOS was 0.36 days shorter in patients cared for by hospitalists, a finding similar to a previous study. Kuo and Goodwin also found a greater difference in LOS in the oldest patients, with a difference of 0.63 days (95% confidence DOI: 10.1111/j.1532-5415.2010.03009.x