Gluing Together a Fragmented Healthcare System for Geriatrics Will Be Hard. It's Time for United Action.

"Gluing" together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: 1) the US's historical fee for service (FFS) reimbursement system; 2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and 3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: 1) local political advocacy to implement health policy legislation; 2) expand geriatric physician and health professional workforce by nontraditional means; and 3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.

Gluing together a fragmented healthcare system for geriatrics will be hard. It's time for united action.

"Gluing" together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: (1) the US's historical fee for service (FFS) reimbursement system; (2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and (3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: (1) local political advocacy to implement health policy legislation; (2) expand geriatric physician and health professional workforce by nontraditional means; and (3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.

Prevalence and Correlates of Uncontrolled Hypertension, Persistently Uncontrolled Hypertension, and Hypertensive Crisis at a Healthcare System.

BACKGROUND: Uncontrolled hypertension significantly increases risk of cardiovascular disease and death. This study examined the prevalence of uncontrolled hypertension, persistently uncontrolled hypertension, and hypertensive crisis and factors associated with these outcomes in a real-world patient cohort. METHODS: Electronic medical records from a large healthcare system in North Carolina were used to identify adults with uncontrolled hypertension (last ambulatory blood pressure [BP] measurement ≥140/90); persistently uncontrolled hypertension (≥2 ambulatory BP measurements with all readings ≥140/90); and hypertensive crisis (any BP reading ≥180/120) in 2019. Generalized linear mixed models tested the association between patient and provider characteristics and each outcome. RESULTS: The study cohort included 213,836 patients (mean age 63.1 (±14.0) years, 55.5% female, 70.8% white). Of these, 29.7% and 13.1% had uncontrolled hypertension and hypertensive crisis, respectively. Among those experiencing hypertensive crisis, >50% did not have uncontrolled hypertension. Of the 171,061 patients with ≥2 BP measurements, 5.9% had persistently uncontrolled hypertension. The likelihood of uncontrolled hypertension, persistently uncontrolled hypertension, and hypertensive crisis was higher in patients with black race (vs. white), self-pay (vs. private), prior emergency room visit, and no attributed primary care provider. Readings taken in the evening (vs. morning) and at specialty (vs. primary care) practices were more likely to meet thresholds for uncontrolled hypertension and hypertensive crisis. CONCLUSIONS: Hypertension control remains a significant challenge in healthcare. Health systems may benefit from segmenting their patient population based on factors such as race, prior healthcare use, and timing of BP measurement to prioritize outreach and intervention.

The Great Health Paradox: A Call for Increasing Investment in Public Health.

The great health paradox is that the least expensive and most effective public health measures available for addressing the COVID-19 pandemic-and other society-wide health challenges-have long been ignored and rejected in the United States in favor of more expensive and personalized care. The U.S. medical system is being overwhelmed in part because of this paradox. The authors argue that the country has invested excessively in acute care medical technology while investing insufficiently in its public health infrastructure. In this Invited Commentary, the authors recommend 5 steps that academic medicine should take to increase emphasis on and understanding of public health interventions to address society's health problems: (1) incorporate problem-based learning experiences in the medical school curriculum and community-based clinical rotations in public health departments, (2) better integrate schools of public health and schools of medicine, (3) encourage physicians to pursue public health careers, (4) educate the public about strategies for decreasing chronic illnesses, and (5) increase collaboration with colleagues around the world to identify and track outbreaks.

Promoting Active Aging: Lessons Learned in an Implementation Pilot in Primary Care.

BACKGROUND: Physical activity (PA) preserves mobility, but few practices screen older adults for mobility impairment or counsel on PA. DESIGN: "Promoting Active Aging" (PAA) was a mixed-methods randomized-controlled pilot, to test the feasibility and acceptability of a video-based PA counseling tool and implementation into practice of two mobility assessment tools. SETTING: Three primary care practices affiliated with Wake Forest Baptist Health. PARTICIPANTS: Adults aged 65 years and older who presented for primary care follow-up and were willing and able to answer self-report questions and walk 4 meters (n = 59). INTERVENTION: Video-based PA counseling intervention versus control video, "Healthy Eating." MEASUREMENTS: Potential participants completed mobility assessments: self-report (Mobility Assessment Tool-short form (MAT-sf)) and performance based (4-meter walk test). We assessed PAA's implementation-feasibility, acceptability, and value-via interviews and surveys. Effectiveness was measured via participant attendance at a PA information session. RESULTS: Of 92 patients approached, 89 (96.7%) agreed to mobility assessment. Eighty-nine completed MAT-sf, and 97.8% (87/89) completed 4-meter walk test. Sixty-seven (75%) met eligibility criteria, and 59 (88%) consented to be randomized either to the PA counseling intervention (Video-PA) or to active control (Video-C). Most participants viewed the walk test positively (51/59; 86.4%). Staff reported that completion of patient surveys, MAT-sf, and videos required significant staff time and support (median = 26 minutes for all), resulting in low acceptability of MAT-sf and the videos. Attendance at a PA information session did not differ by randomization group (Video-PA = 11/29 (37.9%); Video-C = 12/30 (40%); 95% confidence interval for difference in proportion = -0.29 to 0.25). CONCLUSIONS: Mobility assessment, particularly a 4-meter walk test, was feasible in primary care. Tablet-based assessment (MAT-sf) and video counseling tools, selected to reduce staff effort, instead required significant time to implement. Future work to promote PA should identify effective ways to facilitate adoption of PA in sedentary older adults that do not burden staff.

COVID-19: Financial Stress Test for Academic Medical Centers.

The coronavirus (COVID-19) pandemic is having profound effects on the lives and well-being of the world's population. All levels of the nation's public health and health care delivery systems are rapidly adjusting to secure the health infrastructure to manage the pandemic in the United States. As the nation's safety net health care systems, academic medical centers (AMCs) are vital clinical and academic resources in managing the pandemic. COVID-19 may also risk the financial underpinnings of AMCs because their cost structures are high, and they may have incurred large amounts of debt over the last decade as they expanded their clinical operations and facilities. This Invited Commentary reviews existing data on AMC debt levels; summarizes relief provided in the Coronavirus Aid, Relief, and Economic Security Act; and suggests policy options to help mitigate risk.