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Putting Older Patients First

hospital bed

Image from Pixabay

Recently, Dr. Leonore Buckley published a commentary in JAMA on witnessing her brother’s hospitalization and subsequent decline. As a physician and caregiver, she provided a unique perspective on the disjointed, often alienating process of being a hospitalized patient in contemporary medicine.

Most physicians or nurses who have recently worked on an inpatient unit have witnessed this phenomenon. Dr. Buckley outlines some of the challenges in the care of her brother, Tom:

  1. Unclear responsibility. It was unclear to Dr. Buckley who was ultimately responsible for Tom’s care – a single point person whom she could approach with questions. She states: “the medical teams came and went with rotating attendings we never really got to know.”
  2. Iatrogenesis. Tom developed a secondary infection after receiving antibiotics, anasarca after receiving intravenous fluids, and delirium after being in an unfamiliar environment for several days. Older patients are particularly prone to such adverse consequences of hospitalization; for example by one estimate, up to one in three experience delirium.
  3. Immobility. Physical therapy was available only sporadically, and Tom deteriorated in part due to lack of movement. This is all too common in hospitals, with therapists often unavailable on weekends, and stretched thin during the weekday.
  4. Lack of patient-centeredness. Dr. Buckley reports that she felt like she “was standing in front of an express train of technology” that couldn’t be stopped. As one example – Tom went to dialysis in a windowless room from 4-8 PM most evenings, therefore missing dinner. Exhausted afterwards, he refused to eat. Other details as well – the continuous alarms that disrupt sleep, the lack of privacy – are all too familiar.

Dr. Buckley does credit the physicians and nurses with being well-trained and providing well-intentioned care. And in my opinion, individual clinicians don’t deserve blame for this – the problem is one of a healthcare system built for maximum efficiency that, somewhere through the process of adapting quality metrics, discharges before noon, and the latest in advanced monitoring technology, lost sight of what matters most – an individual person, sick and often bewildered, who needs other human beings to help them recover.

This is a complex problem without a single solution, but there is progress on many fronts. For example, the John A. Hartford Foundation has identified  “age-friendly health systems” as a priority area and is working with organizations to achieve several aims, including aligning care with older patients’ specific health goals, implementing delirium prevention strategies, and ensuring mobilization on a daily basis. Medical centers such as Johns Hopkins are piloting rehabilitation programs in critically ill patients, mobilizing them early in their disease course to avoid functional decline.

Such efforts are laudable. And, as the number of Americans age ≥85 is expected to triple over the next three decades, they are essential to a future healthcare system that puts patients first.

 

By: John Dodson, MD, MPH

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Understanding the Peaks and Valleys: Why Do Patients with Heart Failure Leave Hospice?

David Russell Headshot Cropped.pngHospices provide palliative and supportive services to people who are nearing the end of life. More people in the U.S. are using hospice than ever before—recent data indicate that half of those with Medicare insurance who died in 2017 used hospice. Hospices are also serving a more diverse population and reaching people with a range of diseases, including heart failure. While this is encouraging news, patients with heart failure face unique challenges in hospice. Because of difficulties in making accurate prognosis estimates, many patients with heart failure are referred to hospice too early or late in the disease process. Also, heart failure causes sudden changes in physical functioning and symptoms that can be difficult to manage at home. These difficulties can make it more likely that patients with heart failure end up leaving hospice prior to death, an event that is also known as “live discharge.”

A study that we recently published in JACC: Heart Failure found that 30% of patients with heart failure experience a live discharge from hospice. We found that this occurs much more frequently in heart failure compared to other diseases like cancer and stroke. Live discharge can happen for several reasons, including unanticipated medical events that lead to hospitalization, decisions by patients and their families to pursue disease-directed treatments that are not allowed under hospice regulations (“elective revocation”), leaving the hospice’s service area, or having an extended prognosis beyond the six-month eligibility window.

Which heart failure patients are more likely to leave hospice before death–“live discharge”?

Data that we gathered from a large population of patients in New York City allowed us to explore factors that were linked with live discharge from hospice:

  • Younger patients between the ages of 18 and 74 are more likely to leave hospice because of hospitalizations or elective revocations.
  • Patients from underrepresented racial/ethnic backgrounds, including black and Hispanic patients, are more than twice as likely to leave hospice because of hospitalization.
  • Higher functioning patients who are more mobile and less reliant on assistance, measured by scores of 50-70% on the Palliative Performance Scale, are more likely to experience live discharge.

What do hospice nurses and other team members think about the experiences of patients with heart failure?

We talked to interdisciplinary team members at a large hospice agency, including nurses and physicians, to understand more about what patients with heart failure experience when they enroll in hospice. Some of the key issues they discussed were:

  • The unique experience of patients with heart failure—rapid changes in symptoms are common and many patients have complex medication regimens and medical devices like defibrillators that require special care.
  • The limited understanding that many patients have of hospice and their disease—many patients lack a clear sense of what hospice is and its philosophy, or are less prepared and ready to face the end of life.
  • The importance of patients’ social and family context—factors such as education, religion, language, social support, and family dynamics were all cited as playing an important role in the experience of patients with heart failure in hospice.

What does this all mean?

We need to pay closer attention to the experiences of patients with heart failure in hospice—to identify ways to help patients stay comfortable at home and prevent avoidable hospitalizations. Providing cardiac-specific training to hospice teams and caregivers may be instrumental in keeping patients with heart failure continuously enrolled in hospice. Also, efforts to raise awareness about hospice goals of care may also help with reducing barriers to palliative care.

By: David Russell, PhD

Dr. Russell is a Research Scientist in the Center for Home Care Policy & Research at the Visiting Nurse Service of New York and an Assistant Professor of Sociology at Appalachian State University. 

Tailored risk for older adults: SILVER-AMI

dodson%20headshotWe recently published a paper on predicting 30-day readmission for older adults with acute myocardial infarction (AMI) in Circulation: Cardiovascular Quality and Outcomes. Our purpose was to evaluate whether aging-related functional impairments in mobility, cognition, and sensory domains would help to predict whether AMI patients would be readmitted to the hospital within 30 days of discharge, which has been subject of increasing focus by payors and health systems over the past decade. We analyzed data from the SILVER-AMI study, which exclusively enrolled participants aged ≥75 years, and included a detailed assessment of functional impairments.

What we found:

  • Among 3006 study participants with AMI (mean age 81.5 years), 547 (18.2%) were readmitted within 30 days.
  • Readmitted participants were older, with more comorbidities, and had a higher prevalence of functional impairments including disability in activities of daily living (17.0% vs. 13.0%), impaired functional mobility (72.5% vs. 53.6%) and weak grip strength (64.4% versus 59.2%).
  • After statistical modeling, our final risk model included 8 variables: functional mobility, ejection fraction, chronic obstructive pulmonary disease, arrhythmia, acute kidney injury, first diastolic blood pressure, P2Y12 inhibitor use, and general health status. While functional mobility was the only aging-related functional impairment retained in this model, it was also the strongest individual predictor.

Our risk model was well calibrated across categories of risk but had only modest discrimination – meaning there were other factors contributing to readmission risk (for example, related to the care environment or health system), that were not captured in SILVER-AMI.

Our hope is that our score can be used in a practical setting – for example, identifying patients for more intensive post-discharge care. Accordingly, our calculator is freely available at silverscore.org, or in the App Store here.

 

By: John Dodson, MD, MPH

 

There’s an App for That: mHealth and older adults with heart disease

searcyPerfect pairings:  Peanut butter and jelly.  Grilled cheese and tomato soup.  Smartphones and geriatric patients?

While most people probably don’t picture their older adult relatives Facetiming their doctor on their iPhone or sporting a Fitbit to the gym, this could very well be the future of preventive medicine. According to a 2016 Pew Research Center poll, 42% of adults over age 65 owned smartphones, up from 11% in 2011. With this rise in mobile technology ownership, there is new opportunity for patient engagement and management beyond the traditional face-to-face encounter. Older adults, especially those with cardiovascular disease, seem well-positioned to gain considerable benefit from mobile health (mHealth) technology. Their propensity for multimorbid disease, mobility impairment, social isolation, and transportation issues means that older adults have both elevated clinical needs and substantial barriers to traditional care strategies. In order to better understand the relative utility of mHealth technologies in older adult patients, we conducted a narrative literature review recently published in Current Geriatrics Reports.

What did we find?

  • There is a wealth of mHealth apps and wearable devices designed to aid in the monitoring of older adult patients with cardiovascular disease.
  • Adoption of mHealth technology by older adults is impeded by well-documented barriers that are physical, cognitive, and motivational in nature.
  • The physical and cognitive challenges can be partially alleviated with engineered solutions that make the mobile interface easier to use.
  • However, motivational barriers require personalized coaching and social support, which are unlikely to be overcome by engineered solutions alone.
  • Studies to date have shown mixed results when mHealth interventions are adopted. More research is needed to prove their usefulness in the home setting.

What does this mean?

In short, there are still barriers to mHealth becoming standard in the treatment of cardiovascular disease in older adults. That being said, several trials have demonstrated significant improvement in blood pressure monitoring, heart failure management, arrhythmia monitoring, medication adherence, and feelings of social isolation. While it is important to keep in mind that results have been mixed with regard to the efficacy of specific mHealth intervention strategies, it makes logical sense that using smartphones and other devices to gather more patient data points between office visits would facilitate more informed care. It is critical to ensure that these strategies 1) produce trustworthy and reliable information and 2) are cost-effective.

Where do we go from here?

Moving forward, it is essential that mHealth developers incorporate the specific engineering solutions to aging-related problems outlined both in our review article and elsewhere to facilitate use with older adults. We must also continue to investigate whether mHealth interventions can be an effective and appropriate supplement to existing care paradigms in the treatment of cardiovascular disease. Though it is still too early to be certain, we believe there is great potential in mHealth interventions for older adults, and we are excited to see the ways in which technology is incorporated into patient care.

By: Ryan Searcy

Ryan is a 2nd-year medical student at the University of North Carolina-Chapel Hill School of Medicine. Ryan was also a Medical Student Training in Aging Research (MSTAR) Program scholar at NYU School of Medicine, where he participated in aging-related research and geriatrics.

CoMPAdRE: A Connecting Point for Aging Researchers

Ruth Masterson CreberWhat is the CoMPAdRE program?
The CoMPAdRE program is an interprofessional, early career mentorship program for faculty who are interested in patient-centered aging research. The acronym CoMPAdRE stands for Columbia University Mentor Peer Aging Research. Compadre also means “friend or companion,” representing the purpose of this program—to build a network of peer relationships that can be sustained over the course of a career.

Many traditional mentoring programs are structured as dyadic relationships between a senior mentor and junior mentee. However, this traditional dyadic model can put undue pressure on both the mentor and mentee.  Moreover, mentees may have trouble identifying senior mentors who are available and willing to invest the time needed to develop a productive dyadic relationship. This issue is particularly problematic for women and racial and ethnic minorities who traditionally have had less access to professional networks (additional information here) with potential senior mentors. There is a large body of research demonstrating the benefits of mentorship, such as access to career development opportunities; therefore, individuals who are excluded from mentorship opportunities are often disadvantaged with regard to career development. CoMPAdRE seeks to address shortcomings of traditional mentoring programs by offering a new model: a hybrid of a dyadic and peer mentorship model, known as facilitated peer mentorship. The program is led by a senior mentor, Mathew Maurer MD, but the focus is on building a strong, interprofessional peer network.

Why is this program interprofessional?
Over the past decade, the care of older adults has become much more clinically complex and fragmented. As patients live longer with multiple comorbid conditions, they are receiving care from a number of specialized providers, creating greater possibilities for fragmentation in care. Collaborative mentorship teams facilitate sharing of ideas and learning opportunities across disciplines. For example, when caring for older adults with heart failure, programs such as the Heart Failure with Preserved Ejection Fraction Program at Weill Cornell Medicine include physicians, nurses, and social workers. Both holistic patient care and thought leadership require an interprofessional team that bring together specific domain expertise. By bringing together a diverse cohort of health professionals from across the country, CoMPAdRE has facilitated a unique learning experience for sharing ideas, developing skills, and building relationships.

How does CoMPAdRE impact patients?
The value of mentorship goes back to the underlying importance of reducing clinician burnout and supporting sustainability. When healthcare providers feel connected through a common mission, they have more capacity to fully engage with the needs of their patients, and conduct high-impact research focused on improving patient outcomes. Clinicians and researchers thrive most when they feel their work is valued.

What will you take away from this program?
Mentorship and giving back to the community takes place at every career stage. CoMPAdRE has hosted many global leaders in aging including Drs. Luigi Ferrucci, Linda Fried, Stephanie Studenski, Terry Fulmer, Mary Tinetti, and Mark Supiano, among others. Each speaker not only shared their career highlights, but the accompanying personal stories that paralleled the highs and lows of their careers. As a group, we learned how to manage time, stay focused, and most of all, value and cultivate relationships. A major theme of discussion throughout the program was that, over the course of clinical training, skills in management, leadership, and administration are not taught, and yet are expected as part of the job. One of the benefits of this program is that it provides the mentees with a structured opportunity to learn more about these skills with direct application into our clinical practices and programs of research.

Despite being a program for “early career” faculty, we were all encouraged to not only seek out mentorship and support, but to also serve as mentor to others. A critical takeaway point from this program was the necessity of mentoring at all career levels; it is never too early or too late to support others through mentorship.

How can we find out more about the program?
If you are interested in finding out more information about this CoMPAdRE program, you can read more details about this program in the Journal of the American Geriatrics Society.

 

By: Ruth Masterson Creber, PhD, MSc, RN

Ruth Masterson Creber is an Assistant Professor of the Department of Healthcare Policy and Research at Weill Cornell Medicine.