Vidhi Patel

Implementing ACOVE quality indicators as an intervention checklist to improve care for hospitalized older adults

BACKGROUND: Medicare patients account for approximately 50% of hospital days. Hospitalization in older adults often results in poor outcomes. OBJECTIVE: To test the feasibility and impact of using Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs) as a therapeutic intervention to improve care of hospitalized older adults. DESIGN: Post‐test only prospective intervention with a nonequivalent retrospective control group. SETTING: Large tertiary hospital in the greater New York Metropolitan area. PATIENTS: Hospitalized patients, 75 years and over, admitted to medical units. INTERVENTION: A checklist, comprised of four ACOVE QIs, administered during daily interdisciplinary rounds: venous thrombosis prophylaxis (VTE) (QI 1), indwelling bladder catheters (QI 2), mobilization (QI 3), and delirium evaluation (QI 4). MEASUREMENTS: Variables were extracted from electronic medical records with QI compliance as primary outcome, and length of stay (LOS), discharge disposition, and readmissions as secondary outcomes. Generalized linear mixed models for binary clustered data were used to estimate compliance rates for each group (intervention group or control group) in the postintervention period, along with their corresponding 95% confidence intervals. RESULTS: Of the 2,396 patients, 530 were on an intervention unit. In those patients not already compliant with VTE, compliance rate was 57% in intervention vs 39% in control (P < .0056). For indwelling catheters, mobilization, and delirium evaluation, overall compliance was significantly higher in the intervention group 72.2% vs 54.4% (P = .1061), 62.9% vs 48.2% (P < .0001), and 27.9% vs 21.7% (P = .0027), respectively. CONCLUSION: The study demonstrates the feasibility and effectiveness of integrating ACOVE QIs to improve the quality of care in hospitalized older adults.

Opiate Prescribing in Hospitalized Older Adults: Patterns and Outcomes

Whereas opiate prescribing patterns have been well described in outpatient and emergency department settings, they have been less defined in hospitalized older adults. The objective was to describe patterns of opiate prescribing and associated outcomes in hospitalized older adults.

Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”?

To evaluate physician knowledge and perceptions about the American Board of Internal Medicine/American Geriatrics Society (ABIM/AGS) Choosing Wisely recommendations regarding percutaneous endoscopic gastrostomy (PEG) in individuals with advanced dementia.

Warfarin Quality Metrics for Hospitalized Older Adults

Background u2003Warfarins adverse drug events are dangerous, common, and costly. While outpatient warfarin management tools exist, there is a dearth of guidance for inpatients. Objectives u2003We sought to describe a health systems chronic warfarin quality metrics in older inpatients, defined by international normalized ratio (INR) control, explore associations between INR overshoots and clinical outcomes, and identify factors associated with overshoots. Patients/Methods u2003Data on patients 65 years and older who were prescribed chronic warfarin and admitted during January 1, 2014, to June 30, 2016, were extracted through retrospective chart review. We defined overshoots as INRs 5 or greater after 48 hours of hospitalization. Logistic regression modeling was used to determine risks for overshoots and multivariate analysis for overshoots association with length of stay (LOS), bleeding, and mortality. Results u2003Of the 12,107 older inpatients on chronic warfarin, most were 75 years or older (75.7%), female (51.2%), and white (70.0%). While 1,333 (11.0%) of patients had overshoots during the admission, 449 (33.7%) of these reached overshoots after 48 hours. When stratified by overshoots versus no overshoots, LOS more than doubled (15.6 vs. 6.8 days) and the bleed rate was significantly higher (27.4 vs. 8.3%) in the overshoot group. While overall mortality was small (0.4%), the overshoot groups mortality was significantly higher (3.12 vs. 0.28%). Black race and weight were protective against overshoots; history of heart failure and antibiotic/amiodarone exposure were predictive of overshoots. Conclusion u2003This is the largest study examining warfarin quality metrics for hospitalized adults, specifically older inpatients. Our model may serve as the basis for identifying high-risk warfarin patients to target interventions to reduce adverse drug events.

Do-Not-Resuscitate Orders in Older Adults During Hospitalization: A Propensity Score-Matched Analysis: DNR orders in hospitalized older patients

To explore the effect of the presence and timing of a do‐not‐resuscitate (DNR) order on short‐term clinical outcomes, including mortality.

A Multicomponent Model to Improve Hospital Care of Older Adults with Cognitive Impairment: A Propensity Score-Matched Analysis: Hospital Care for Persons with Dementia

To determine whether a multicomponent intervention improves care in hospitalized older adults with cognitive impairment.

The role of geriatrician-hospitalists in the care of older adults: A retrospective cohort study

INTRODUCTIONnMedicare patients account for over 50% of hospital days at a cost of over

Nonadherence to Geriatric-Focused Practices in Older Intensive Care Unit Survivors

1 trillion per year. Yet, hospitalization of older adults often results in poor outcomes. We evaluated the role of geriatrician-hospitalists in the care of older adults. Materials and methods A retrospective cohort study was conducted in a 764-bed tertiary care hospital with patients 65 and older admitted to medicine. Geriatrician-hospitalists care was compared to usual care by non-geriatrician hospitalists (staff and non-staff). Outcome measures included length of stay (LOS) and 30-day readmissions. Process measures included geriatric-focused care practices, such as early mobilization, safety precautions, delirium management, use of potentially inappropriate medications and documentation of advanced directives as well as discharge disposition.nnnRESULTSnOf the 10,529 patients, 2949 (28.0%) were cared for by staff hospitalists, 7181 (68.2%) by non-staff hospitalists and 399 (3.79%) by geriatrician-hospitalists. Patients cared for by geriatrician-hospitalists were significantly older with more comorbidities than those admitted to staff and non-staff hospitalists (average age: 86.3, 79.7, and 80.3, respectively, pu202f<u202f0.0001; Charlson Comorbidity Index: 7.46, 7.01, and 7.17, respectively, pu202f=u202f0.0005). Multivariate analysis showed no difference in LOS, 30-day readmissions, and discharge disposition. In terms of care practices, significant differences were found for the following: time to PT (pu202f<u202f0.0001), duration of indwelling bladder catheters (pu202f=u202f0.018), documentation of Do-Not-Resuscitate (pu202f<u202f0.0001), benzodiazepine use (pu202f<u202f0.0001) and anticholinergics (pu202f=u202f0.0029), respectively.nnnCONCLUSIONSnAs the population continues to age at unprecedented rates and hospitals struggle to meet the demands and expectations, geriatrician-hospitalists may improve care practices important for older adult care management.

Measuring Functional Status in Hospitalized Older Adults Through Electronic Health Record Documentation

Background Older adults account for more than half of all admissions to intensive care units; most remain alive at 1 year, but with long‐term sequelae. Objective To explore geriatric‐focused practices and associated outcomes in older intensive care survivors. Methods In a 1‐year, retrospective, cohort study of patients admitted to the medical intensive care unit and subsequently transferred to the medicine service, adherence to geriatric‐focused practices and associated clinical outcomes during intensive care were determined. Results A total of 179 patients (mean age, 80.5 years) met inclusion criteria. Nonadherence to geriatric‐focused practices, including nothing by mouth (P = .004), exposure to benzodiazepines (P = .007), and use of restraints (P < .001), were associated with longer stay in the intensive care unit. Nothing by mouth (P = .002) and restraint use (P = .003) were significantly associated with longer hospital stays. Bladder catheters were associated with hospital‐acquired pressure injuries (odds ratio, 8.9; 95% CI, 1.2–67.9) and discharge to rehabilitation (odds ratio, 8.9; 95% CI, 1.2–67.9). Nothing by mouth (odds ratio, 3.2; 95% CI, 1.2–8.0) and restraints (odds ratio, 2.8; 95% CI, 1.4–5.8) were also associated with an increase in 30‐day readmission. Although 95% of the patients were assessed at least once by using the Confusion Assessment Method for the Intensive Care Unit (overall 2334 assessments documented), only 3.4% had an assessment that indicated delirium; 54.6% of these assessments were inaccurate. Conclusion Although initiatives have increased awareness of the challenges, implementation of geriatric‐focused practices in intensive care is inconsistent.