Creating a Palliative Care Inpatient Response Plan for COVID-19-The UW Medicine Experience.

CONTEXT: The coronavirus disease 2019 (COVID-19) pandemic is stressing health care systems throughout the world. Significant numbers of patients are being admitted to the hospital with severe illness, often in the setting of advanced age and underlying comorbidities. Therefore, palliative care is an important part of the response to this pandemic. The Seattle area and UW Medicine have been on the forefront of the pandemic in the U.S. METHODS: UW Medicine developed a strategy to implement a palliative care response for a multihospital health care system that incorporates conventional capacity, contingency capacity, and crisis capacity. The strategy was developed by our palliative care programs with input from the health care system leadership. RESULTS: In this publication, we share our multifaceted strategy to implement high-quality palliative care in the context of the COVID-19 pandemic that incorporates conventional, contingency, and crisis capacity and focuses on the areas of the hospital caring for the most patients: the emergency department, intensive care units, and acute care services. The strategy focuses on key content areas, including identifying and addressing goals of care, addressing moderate and severe symptoms, and supporting family members. CONCLUSION: Strategy planning for delivery of high-quality palliative care in the context of the COVID-19 pandemic represents an important area of need for our health care systems. We share our experiences of developing such a strategy to help other institutions conduct and adapt such strategies more quickly.

Suboptimal osteoporosis evaluation and treatment in older men with and without additional high-risk factors for fractures.

We compared osteoporosis case-finding, evaluation and treatment in groups of Older Men and Older Women with age alone as a significant risk for fracture and Older Men with Higher Risk (older men additionally having previous hip fracture, corticosteroid use or androgen deprivation therapy). We studied 13,704 older men and women (≥70 years old) receiving care at a Veterans Affairs medical center from January 2000 to August 2010 whose 10-year hip fracture risk was assessed by limited FRAX score. The main outcome measures were the proportion of patients who had bone mineral density (by dual-energy X-ray absorptiometry [DXA]) and serum 25-hydroxy vitamin D (25-OH D) measurements performed, and calcium/vitamin D or bisphosphonates prescribed. The proportion of men with a 10-year hip fracture risk ≥3% with age alone as a risk was 48% and 88% in men aged 75-79 and ≥80 years, respectively. Compared with Older Women, fewer Older Men underwent DXA (12% vs 63%, respectively) and 25-OH D measurements (18% vs 39%), and fewer received calcium/vitamin D (20% vs 63%) and bisphosphonate (5% vs 44%) prescriptions. In Older Men with Higher Risk category, the proportion of men with 10-year hip fracture risk ≥3% ranged from 69% to 95%. Despite a higher risk and expectation that this group would have greater case detection and screening, few Older Men with Higher risk underwent DXA screening (27%-36%) and 25-OH D measurements (23%-28%), and received fewer calcium/vitamin D (40%-50%) and bisphosphonate (13%-24%) prescriptions. Considering the known morbidity and mortality, our findings underscore the need for improved evaluation and management of osteoporosis in older men at high risk for fracture.

Dutasteride reduces prostate size and prostate specific antigen in older hypogonadal men with benign prostatic hyperplasia undergoing testosterone replacement therapy.

PURPOSE: Benign prostatic hyperplasia and hypogonadism are common disorders in aging men. There is concern that androgen replacement in older men may increase prostate size and symptoms of benign prostatic hyperplasia. We examined whether combining dutasteride, which inhibits testosterone to dihydrotestosterone conversion, with testosterone treatment in older hypogonadal men with benign prostatic hyperplasia reduces androgenic stimulation of the prostate compared to testosterone alone. MATERIALS AND METHODS: We conducted a double-blind, placebo controlled trial of 53 men 51 to 82 years old with symptomatic benign prostatic hyperplasia, prostate volume 30 cc or greater and serum total testosterone less than 280 ng/dl (less than 9.7 nmol/l). Subjects were randomized to daily transdermal 1% T gel plus oral placebo or dutasteride for 6 months. Testosterone dosing was adjusted to a serum testosterone of 500 to 1,000 ng/dl. The primary outcomes were prostate volume measured by magnetic resonance imaging, serum prostate specific antigen and androgen levels. RESULTS: A total of 46 subjects completed all procedures. Serum testosterone increased similarly into the mid-normal range in both groups. Serum dihydrotestosterone increased in the testosterone only but decreased in the testosterone plus dutasteride group. In the testosterone plus dutasteride group prostate volume and prostate specific antigen (mean ± SEM) decreased 12% ± 2.5% and 35% ± 5%, respectively, compared to the testosterone only group in which prostate volume and prostate specific antigen increased 7.5% ± 3.3% and 19% ± 7% (p = 0.03 and p = 0.008), respectively, after 6 months of treatment. Prostate symptom scores improved in both groups. CONCLUSIONS: Combined treatment with testosterone plus dutasteride reduces prostate volume and prostate specific antigen compared to testosterone only. Coadministration of a 5α-reductase inhibitor with testosterone appears to spare the prostate from androgenic stimulation during testosterone replacement in older, hypogonadal men with symptomatic benign prostatic hyperplasia.

Clinical yield of computed tomography brain scans in older general medical patients.

OBJECTIVES: To evaluate the clinical yield of computed tomography (CT) brain scans in a prospective cohort of older patients admitted to the general medicine service. DESIGN: Nested cohort study of 117 subjects enrolled in previous prospective cohort study of 919 subjects. SETTING: University-affiliated teaching hospital. PARTICIPANTS: Hospitalized general medical patients aged 70 and older who received one or more brain CT scans during their hospital stay. MEASUREMENTS: Review of medical records and interpretation of the first brain CT scan in these 117 patients for indications for ordering scans and clinically significant brain abnormalities. Medical records of patients with brain CT scans with abnormalities were reviewed for 2 weeks after the scan for changes in medical management resulting from scan findings. Three independent reviewers adjudicated the presence of abnormalities and resulting treatment changes. RESULTS: Of the 117 brain CT scans, 32 (27%) were ordered to exclude intracranial hemorrhage, 30 (26%) to exclude cerebrovascular accident (CVA), 16 (14%) for falls, 15 (13%) for syncope, seven (6%) to exclude subdural hemorrhage, five (4%) for mental status change, and 12 (10%) for other reasons. Of the 117 brain CT scans, 29 (25%) had abnormalities, including acute CVA or hemorrhage, old CVA, meningioma, and other abnormalities. Only 10 (9% of all scans, 34% of abnormal scans) resulted in treatment changes (including consultations, further imaging, stroke evaluation, and drug changes). The presence of focal neurological deficits was significantly associated with treatment changes after CT scans (odds ratio=13.2, 95% confidence interval=1.7-161.5). CONCLUSION: These results suggest that the overall clinical yield of brain CT scans in unselected older hospitalized patients is low. Targeting scans toward patients with new focal neurological deficits will help to improve clinical yield.