Community physician education in geriatrics: applying the assessing care of vulnerable elders model with a multisite primary care group.

Providing practicing physicians with effective education that leads to better patient outcomes remains challenging. In 2003, the University of Cincinnati College of Medicine developed a comprehensive program to enhance practicing physician geriatric medicine education based on the Assessing the Care of Vulnerable Elders model. The program was implemented with a large, multisite primary care group based in the greater Cincinnati area and was designed to increase physicians' clinical skills and assist them in implementing new office and system strategies that could improve the quality of care for their older patients. Four topic areas were chosen: medication management, falls and mobility, urinary incontinence, and dementia. A multifaceted physician education program was developed for each topic area, with lunch-time, in-office, geriatrician-led presentations as the primary intervention. Over a 4-year period (2004-2007), more than 60 physicians in 16 primary care practices attended 107 teaching sessions. The value of the presentation content, quality of the presentations, and perception of meeting the primary care physicians' (PCPs') educational needs were each rated at 3.8 or above (4=excellent). Between 80% and 92% of the PCPs planned to make a change in their practice behavior as a result of the training, but only two offices initiated formal quality improvement projects. During the teaching sessions, the PCPs were provided with screening tools to identify "at risk" patients, assessment chart templates, and community resource and patient education materials. The application of a modified version of the ACOVE model to reach a large group of primary care physicians is possible and may be one strategy to improve the assessment and management of geriatric syndromes.

Asian-Indian physicians' experience with managed care organizations.

PURPOSE: There is anecdotal evidence that ethnic minority physicians are underrepresented in managed care contracts. The purpose of this paper, therefore, is to determine ethnic Asian-Indian physician-managed care organization experience and job satisfaction in the USA by age, gender, region and percent of patients in managed care organizations. DESIGN/METHODOLOGY/VALUE: A random (nation-wide) mail survey was conducted of 254 physicians who were American Association of Physicians of Indian Origin (AAPI) members during the period 1998 to 2000. Managed care experience was categorized into physician satisfaction; service quality rating; service limitations; difficulties acquiring and maintaining managed care contracts; and financial impact. FINDINGS: Physicians in solo and group practice relied heavily on managed care enrolled patients. Limitations providing care to patients was a more serious problem than for those in staff-model health maintenance organization and hospital/clinic-based practices. Physician satisfaction was not significantly related to board certification, practice type, region and managed care participation. However, practice staff participating in managed care had the highest number of board-certified physicians. RESEARCH LIMITATIONS/IMPLICATIONS: There was a low response rate (37 percent) to data collection using questionnaires. PRACTICAL IMPLICATIONS: The paper underlines ethnic minority physicians' capability to get managed care contracts. ORIGINALITY/VALUE: This is the first national study of Asian-Indian physicians and their managed care organization experience. Asian-Indian physicians are over-represented in the medical profession and hence the paper will interest those working and dealing with managed care organizations and their patients.

Use of monofilament in the detection of foot lesions in older adults.

The purpose of this study was to compare Semmes-Weinstein monofilament testing between elderly and young patients in both a diabetic and nondiabetic population. Monofilament mapping (10 g) was performed on 115 patients: 74 who were greater than 60 years of age (47 with diabetes) and 41 who were younger than 60 years (20 with diabetes). Sensations were assessed at 15 predefined pressure/risk points. Sensations were found to have perfect correlation between the same point on the left and right foot (r = 1.0) for each of the 15 points. The data for the 15 points were divided in 2 subsets: one for 8 points similar to a validated method and another with 7 new points on the dorsum and ankle area. Scores on both subsets differed significantly by age group (P < .0001) and diabetes status (P < .001), with older patients and patients with diabetes having higher scores. Analysis of covariance was used to estimate 15-point scores for the 4 combinations of age group and diabetes status, adjusting for foot ulceration, callus, deformity, and ischemia. In older patients without diabetes, each subset score was used to detect future neuropathy if 4 or more points were insensitive. The detections agreed in 37 of 47 cases. In all 10 cases of disagreement, the 7-point subset detected no neuropathy, suggesting that inclusion of the additional points could improve diagnostic specificity. The significant differences noted between young and old patients suggest the importance of aging-related changes, and raise questions about current scoring methods for detection of neuropathy in older adults with diabetes.

Hyaluronic acid injections relieve knee pain.

OBJECTIVE: To evaluate the efficacy of intra-articular viscosupplementation therapy with hyaluronic acid for pain relief of knee osteoarthritis, we conducted a meta-analysis of randomized, double-blinded, placebo-controlled trials. METHODS: We searched systematically for randomized, double-blinded, placebo-controlled trials of hyaluronic acid (hyaluronan and hylan G-F20) for pain relief of knee osteoarthritis. Studies reporting pain visual analogue scale (VAS) differences were included in the meta-analysis. Changes in pain were measured by VAS for placebo and treatment, and summary estimates of the differences between the 2 arms were calculated at 1 week, 5 to 7 weeks, 8 to 12, and 15 to 22 weeks after the last intra-articular injection. Sources of heterogeneity were assessed using information on quality score, type of viscosupplementation, and VAS change in pain with activity or rest. Heterogeneity across the studies was significant in all analyses (P<.01); therefore a random effect model was used. Pain was measured either on activity or at rest. RESULTS: Eleven trials (9 hyaluronan and 2 hylan G-F 20) allowed calculation of the summary estimate of difference in change of VAS pain at 1 week, 6 of the 11 allowed the estimation between 5 to 7 weeks and 8 to 12 weeks, and only 3 at 15 to 22 weeks. The summary estimates of VAS differences between therapy and placebo injection: at 1 week, 4.4 (95% confidence interval [CI], 1.1-7.2); at 5 to 7 weeks, 17.7 (7.5-28.0); at 8 to 12 weeks, 18.1 (6.3-29.9) and at 15 to 22 weeks, 4.4 (-15.3 to 24.1). CONCLUSION: Intra-articular viscosupplementation was moderately effective in relieving knee pain in patients with osteoarthritis at 5 to 7 and 8 to 10 weeks after the last injection but not at 15 to 22 weeks.

Management of geriatric endocrine disorders.

Endocrine disorders in older adults are often detected on screening for unrelated medical conditions. Many disorders are precipitated during periods of stress. Despite a decline in certain hormonal levels endocrine functions of significance are well preserved in healthy older adults.

Weaning success among ventilator-dependent patients in a rehabilitation facility.

OBJECTIVES: To determine outcomes of difficult-to-wean, ventilator-dependent patients transferred from intensive care units to rehabilitation hospitals and to determine predictors of weaning success in such patients. DESIGN: A retrospective cohort study. SETTING: A rehabilitation facility. PARTICIPANTS: One hundred forty-five difficult-to-wean patients (55.2% men; 83.4% white; mean age +/- standard deviation, 65.8 +/- 16.4y) transferred to a rehabilitation facility between July 1994 and June 1996. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic and clinical data, including variables identified previously as predictive of weaning success among highly selected populations. RESULTS: Patients' Gillespie categories (reason for ventilator dependency) included "other medical conditions" (eg, pneumonia, neurologic) in 42.1% of the cases, postoperative in 24.8%, previous lung disease (eg, chronic obstructive pulmonary disease, interstitial lung disease) in 15.2%, trauma in 11.7%, respiratory failure with multisystem failure in 3.4%, and uncomplicated acute lung injury (acute respiratory distress syndrome) in 2.8%. Of 145 patients, 50.3% were completely weaned, 4.8% were partially weaned, and 44.8% remained ventilator dependent. In a stepwise multivariable logistic regression analysis, significant predictors of weaning success included white race (odds ratio [OR] = 3.4), serum albumin level (OR = 2.1g/dL), and blood urea nitrogen (BUN) level (OR = .97mg/dL); in addition, compared with postoperative patients, patients with "other medical conditions" (OR = .15) or previous lung disease (OR = .08) were less likely to be weaned (area under receiver operating characteristic curve = .76). Among 31 long-term survivors who were interviewed at least 6 months after discharge from the rehabilitation facility, 58.1% rated their health-related quality of life as good or better. CONCLUSIONS: Half of the patients admitted to a rehabilitation facility were weaned from their ventilators. Predictors of weaning success included race, BUN level, albumin level, and reason for ventilator dependency.