Geriatrics Curricula for Internal and Family Medicine Residents: Assessing Study Quality and Learning Outcomes.

BACKGROUND: Prior reviews of geriatrics curricula for internal medicine (IM) and family medicine (FM) residents have not evaluated study quality or assessed learning objectives or specific IM or FM competencies. OBJECTIVE: This review of geriatrics curricula for IM and FM residents seeks to answer 3 questions: (1) What types of learning outcomes were measured? (2) How were learning outcomes measured? and (3) What was the quality of the studies? METHODS: We evaluated geriatrics curricula that reported learning objectives or competencies, teaching methods, and learning outcomes, and those that used a comparative design. We searched PubMed and 4 other data sets from 2003-2015, and assessed learning outcomes, outcome measures, and the quality of studies using the Medical Education Research Study Quality Instrument (MERSQI) and Best Evidence Medical Education (BEME) methods. RESULTS: Fourteen studies met inclusion criteria. Most curricula were intended for IM residents in the inpatient setting; only 1 was solely dedicated to FM residents. Median duration was 1 month, and minimum geriatrics competencies covered were 4. Learning outcomes ranged from Kirkpatrick levels 1 to 3. Studies that reported effect size showed a considerable impact on attitudes and knowledge, mainly via pretests and posttests. The mean MERSQI score was 10.5 (range, 8.5-13) on a scale of 5 (lowest quality) to 18 (highest quality). CONCLUSIONS: Few geriatrics curricula for IM and FM residents that included learning outcome assessments were published recently. Overall, changes in attitudes and knowledge were sizeable, but reporting was limited to low to moderate Kirkpatrick levels. Study quality was moderate.

Characterization, risk stratification and the hypertension control rate at hospital-based clinics: a survey of 25,336 hypertensives in Beijing, Shanghai and Guangzhou.

OBJECTIVE: To characterize hypertensive patients living in metropolitan cities in China. METHODS: This was a cross-sectional survey conducted in Beijing, Shanghai and Guangzhou. The eligibility criteria included outpatients 35-85 years of age with a systolic blood pressure (SBP) of ≥140 mmHg or a diastolic blood pressure (DBP) of ≥90 mmHg or both and/or patients receiving antihypertensive medications. The patients' demographic characteristics, medical history and findings of physical examinations, laboratory tests and cardiovascular imaging (i.e., ultrasonic cardiogram) were included in the survey. Risk stratification and the rate of hypertension control were evaluated. RESULTS: A total of 25,336 individuals were surveyed, of which 79.1% were from cardiology clinics and 51.8% were male hypertensives. The average SBP/DBP was 139.3±18.6/82.3±12.0 mmHg. The mean age was 63.6±11.5 years. The mean BMI was 25.1±3.8 kg/m(2). Among the men, 55.9% had a waist circumference of >90 cm. Among the women, 50.9% had a waist circumference of >85 cm. The percentages of patients with diabetes mellitus, heart disease and cerebral vascular disease were 20.3%, 39.2% and 10.4%, respectively. The smoking rate was 17.6%. Overall, 60.9% of the patients were in the very high risk group. While 97.7% of the patients were receiving antihypertensive drug therapy, only 40.2% had controlled SBP/DBP (i.e., under 140/90 mmHg). The control rate was statistically higher in Beijing and Shanghai than in Guangzhou and among older patients than among younger patients (43% among the patients >75 years of age vs. 28.1% among the patients 35-45 years of age). CONCLUSION: In Beijing, Shanghai and Guangzhou, most hypertensive patients have various cardiovascular risk factors and cardiovascular diseases. High blood pressure is not under appropriate control in all cases, especially among young hypertensives and patients living in Guangzhou city. Approaches designed to target multiple risk factors and concomitant cardiovascular diseases and boost the hypertension control rate are warranted.

Characteristics of advanced cancer patients with cancer-related fatigue enrolled in clinical trials and patients referred to outpatient palliative care clinics.

CONTEXT: Limited published data exist on whether characteristics of patients with advanced cancer enrolled in cancer-related fatigue clinical trials (CCTs) differ from patients in outpatient palliative care clinics (OPCs). OBJECTIVES: The primary aim of this study was to compare the characteristics of two groups of patients with advanced cancer and moderate-to-severe fatigue: patients in CCTs and patients at an OPC. METHODS: We retrospectively reviewed the records of 337 patients who were enrolled in one of five CCTs for advanced cancer patients at The University of Texas M. D. Anderson Cancer Center as well as the records of 1896 consecutive patients who were referred to our OPC from January 2003 through December 2010. Patients with fatigue scores of ≥4/10 (measured by the Edmonton Symptom Assessment System [ESAS]) were eligible (1252 OPC patients and 337 CCT patients). Patient characteristics, ESAS scores, and survival times were compared using Chi-square tests, Wilcoxon rank sum tests, and the Kaplan-Meier method. RESULTS: Compared with the CCT patients, OPC patients were more likely to be older (58 vs. 59 years; P=0.009) and male (38% vs. 52%; P<0.001). The most common primary cancer type was breast cancer (22%) in the CCT patients and lung cancer (23%) in the OPC patients (P<0.001). The median ESAS scores in the OPC and CCT groups, respectively, were 6 and 4 for pain (P<0.001), 7 and 7 for fatigue (P=0.525), 3 and 2 for depression (P=0.004), 3 and 2 for anxiety (P<0.001), 3 and 2 for dyspnea (P<0.001), and 43 and 32 for the symptom distress score (P<0.001). The median overall survival times were 17.9 months (95% CI 13.5-22.3 months) in the CCT group and 3.8 months (95% CI 3.5-4.1 months) in the OPC group (P<0.001). CONCLUSION: Baseline characteristics and overall survival times significantly differed between patients enrolled in the CCT and OPC groups. Therefore, we conclude that the results of CCTs cannot be generalized to patients being treated in OPCs.

Assessing the quality of evidence from randomized, controlled drug and nutritional supplement trials conducted among nursing home residents between 1968 and 2004: what can we learn?

BACKGROUND: An estimated 1.5 million residents of nursing homes (NH) in the United States were prescribed an average of 7 to 8 medications each month. However, it is unknown which of these prescribed drugs and nutritional supplements have been tested for use among NH residents who often have distinct and complex needs compared with other geriatric patients. This pilot study addresses the quantity and quality of randomized, controlled drug and nutritional supplement trials that have been conducted among NH residents. METHOD: Using multiple search strategies and review protocol, I assessed the quality of evidence from randomized, controlled drug and nutritional supplement trials that had a parallel-group design, were conducted among NH residents, and were published in English between 1968 and October 2004. Internal validity of the trials was examined by assessing adequately reporting power calculation, drop-outs (completion fraction), randomization and allocation concealment, blind status, and intention-to-treat analysis. External validity of the trials was examined by assessing adequately reporting the sample description, the inclusion and exclusion criteria, the recruitment process, and comorbidities and harm. RESULT: Relatively few drug and nutritional supplements have been tested among NH residents by well-designed and executed randomized controlled trials (N = 42). The total number of participants (N = 7941) is small. The quality of many trials is poor. CONCLUSIONS: Given the limited number and poor quality of existing trials conducted among NH residents in this pilot study, I conclude that there is a limited body of evidence that could be used to establish quality of care standards or pay for performance criteria for drug therapy and nutritional supplements in NH. Long-term care providers face a great challenge in practicing evidence-based medicine in prescribing drugs and nutritional supplements.