Impact of comprehensive medication reviews on potentially inappropriate medication discontinuation in Medicare beneficiaries.

BACKGROUND: The use of potentially inappropriate medications (PIMs) is associated with increased risk of hospitalizations and emergency room visits and varies by racial and ethnic subgroups. Medicare's nationwide medication therapy management (MTM) program requires that Part D plans offer an annual comprehensive medication review (CMR) to all beneficiaries who qualify, and provides a platform to reduce PIM use. The objective of this study was to assess the impact of CMR on PIM discontinuation in Medicare beneficiaries and whether this differed by race or ethnicity. METHODS: Retrospective cohort study of community-dwelling Medicare Part D beneficiaries ≥66 years of age who were eligible for MTM from 2013 to 2019 based on 5% Medicare fee-for-service claims data linked to the 100% MTM data file. Among those using a PIM, MTM-eligible CMR recipients were matched to non-recipients via sequential stratification. The probability of PIM discontinuation was estimated using regression models that pooled yearly subcohorts accounting for within-beneficiary correlations. The most common PIMs that were discontinued after CMR were reported. RESULTS: We matched 24,368 CMR recipients to 24,368 CMR non-recipients during the observation period. Median age was 74-75, 35% were males, most were White beneficiaries (86%-87%), and the median number of PIMs was 1. In adjusted analyses, CMR receipt was positively associated with PIM discontinuation (adjusted relative risk [aRR]: 1.26, 95% CI: 1.20-1.32). There was no evidence of differential impact of CMR by race or ethnicity. The PIMs most commonly discontinued after CMR were glimepiride, zolpidem, digoxin, amitriptyline, and nitrofurantoin. CONCLUSIONS: Among Medicare beneficiaries who are using a PIM, CMR receipt was associated with PIM discontinuation, suggesting that greater CMR use could facilitate PIM reduction for all racial and ethnic groups.

Factors influencing central nervous system medication deprescribing and behavior change in hospitalized older adults.

BACKGROUND: Central nervous system (CNS) medications are linked to higher morbidity and mortality in older adults. Hospitalization allows for deprescribing opportunities. This qualitative study investigates clinician and patient perspectives on CNS medication deprescribing during hospitalization using a behavioral change framework, aiming to inform interventions and identify recommendations to enhance hospital deprescribing processes. METHODS: This qualitative study focused on hospitalists, primary care providers, pharmacists, and patients aged ≥60 years hospitalized on a general medicine service and prescribed ≥1 CNS medications. Using semi-structured interviews and focus groups, we aimed to evaluate patient medication knowledge, prior deprescribing experiences, and decision-making preferences, as well as provider processes and tools for medication evaluation and deprescribing. Rapid qualitative analysis applying the Capability, Opportunity, Motivation, and Behavior (COM-B) framework revealed themes influencing deprescribing behavior in patients and providers. RESULTS: A total of 52 participants (20 patients and 32 providers) identified facilitators and barriers across deprescribing steps and generated recommended strategies to address them. Clinicians and patients highlighted the opportunity for CNS medication deprescribing during hospitalizations, facilitated by multidisciplinary teams enhancing clinicians' capability to make medication changes. Both groups also stressed the importance of intensive patient engagement, education, and monitoring during hospitalizations, acknowledging challenges in timing and extent of deprescribing, with some patients preferring decisions deferred to outpatient clinicians. Hospitalist and pharmacist recommendations centered on early pharmacist involvement for medication reconciliation, expanding pharmacy consultation and clinician education on deprescribing, whereas patients recommended enhancing shared decision-making through patient education on medication adverse effects, tapering plans, and alternatives. Hospitalists and PCPs also emphasized standardized discharge instructions and transitional care calls to improve medication review and feedback during care transitions. CONCLUSIONS: Clinicians and patients highlighted the potential advantages of hospital interventions for CNS medication deprescribing, emphasizing the necessity of addressing communication, education, and coordination challenges between inpatient and outpatient settings.

Deprescribing in older adults with polypharmacy.

Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.

Comprehensive Medication Review Completion Rates and Disparities After Medicare Star Rating Measure.

Importance: Comprehensive medication reviews (CMRs) are offered to qualifying US Medicare beneficiaries annually to optimize medication regimens and therapeutic outcomes. In 2016, Medicare adopted CMR completion as a Star Rating quality measure to encourage the use of CMRs. Objective: To examine trends in CMR completion rates before and after 2016 and whether racial, ethnic, and socioeconomic disparities in CMR completion changed. Design, Setting, and Participants: This observational study using interrupted time-series analysis examined 2013 to 2020 annual cohorts of community-dwelling Medicare beneficiaries aged 66 years and older eligible for a CMR as determined by Part D plans and by objective minimum eligibility criteria. Data analysis was conducted from September 2022 to February 2024. Exposure: Adoption of CMR completion as a Star Rating quality measure in 2016. Main Outcome and Measures: CMR completion modeled via generalized estimating equations. Results: The study included a total of 561 950 eligible beneficiaries, with 253 561 in the 2013 to 2015 cohort (median [IQR] age, 75.8 [70.7-82.1] years; 90 778 male [35.8%]; 6795 Asian [2.7%]; 24 425 Black [9.6%]; 7674 Hispanic [3.0%]; 208 621 White [82.3%]) and 308 389 in the 2016 to 2020 cohort (median [IQR] age, 75.1 [70.4-80.9] years; 126 730 male [41.1%]; 8922 Asian [2.9%]; 27 915 Black [9.1%]; 7635 Hispanic [2.5%]; 252 781 White [82.0%]). The unadjusted CMR completion rate increased from 10.2% (7379 of 72 225 individuals) in 2013 to 15.6% (14 185 of 90 847 individuals) in 2015 and increased further to 35.8% (18 376 of 51 386 individuals) in 2020, in part because the population deemed by Part D plans to be MTM-eligible decreased by nearly half after 2015 (90 487 individuals in 2015 to 51 386 individuals in 2020). Among a simulated cohort based on Medicare minimum eligibility thresholds, the unadjusted CMR completion rate increased but to a lesser extent, from 4.4% in 2013 to 12.6% in 2020. Compared with White beneficiaries, Asian and Hispanic beneficiaries experienced greater increases in likelihood of CMR completion after 2016 but remained less likely to complete a CMR. Dual-Medicaid enrollees also experienced greater increases in likelihood of CMR completion as compared with those without either designation, but still remained less likely to complete CMR. Conclusion and Relevance: This study found that adoption of CMR completion as a Star Rating quality measure was associated with higher CMR completion rates. The increase in CMR completion rates was achieved partly because Part D plans used stricter eligibility criteria to define eligible patients. Reductions in disparities for eligible Asian, Hispanic, and dual-Medicaid enrollees were seen, but not eliminated. These findings suggest that quality measures can inform plan behavior and could be used to help address disparities.

Central nervous system medication use around hospitalization.

BACKGROUND: Central nervous system (CNS) medication use is common among older adults, yet the impact of hospitalizations on use remains unclear. This study details CNS medication use, discontinuations, and user profiles during hospitalization periods. METHODS: Retrospective cohort study using electronic health records on patients ≥65 years, from three hospitals (2018-2020), and prescribed a CNS medication around hospitalization (90 days prior to 90 days after). Latent class transitions analysis (LCTA) examined profiles of CNS medication class users across four time points (90 days prior, admission, discharge, 90 days after hospitalization). RESULTS: Among 4666 patients (mean age 74.3 ± 9.3 years; 63% female; 70% White; mean length of stay 4.6 ± 5.6 days (median 3.0 [2.0, 6.0]), the most commonly prescribed CNS medications were antidepressants (56%) and opioids (49%). Overall, 74% (n = 3446) of patients were persistent users of a CNS medication across all four time points; 7% (n = 388) had discontinuations during hospitalization, but of these, 64% (216/388) had new starts or restarts within 90 days after hospitalization. LCTA identified three profile groups: (1) low CNS medication users, 54%-60% of patients; (2) mental health medication users, 30%-36%; and (3) acute/chronic pain medication users, 9%-10%. Probability of staying in same group across the four time points was high (0.88-1.00). Transitioning to the low CNS medication use group was highest from admission to discharge (probability of 9% for pain medication users, 5% for mental health medication users). Female gender increased (OR 2.4, 95% CI 1.3-4.3), while chronic kidney disease lowered (OR 0.5, 0.2-0.9) the odds of transitioning to the low CNS medication use profile between admission and discharge. CONCLUSIONS: CNS medication use stays consistent around hospitalization, with discontinuation more likely between admission and discharge, especially among pain medication users. Further research on patient outcomes is needed to understand the benefits and harms of hospital deprescribing, particularly for medications requiring gradual tapering.

Deprescribing electronic case reviews for older veterans at risk for falls: Effects on drug burden and falls.

BACKGROUND: Falls are the most common medication-related safety event in older adults. Deprescribing fall risk-increasing drugs (FRIDs) may mitigate fall risk. This study assesses the effects of an innovative deprescribing program in reducing FRID burden and falls-related acute visits over 1 year. METHODS: The Falls Assessment of Medications in the Elderly (FAME) Program is a pilot deprescribing program designed to improve medication safety in Veterans aged ≥65, screening positive for high fall risk at the Durham Veterans Affairs Health Care System. Central case finding and electronic case reviews with deprescribing recommendations were completed by an interdisciplinary team, forwarded to prescribers for approval, then implemented during follow-up telephone visits by FAME team. Primary outcome was change in FRID burden calculated by modified Drug Burden Index (DBI) at 1 year and an exploratory outcome was 1-year fall-related acute visits. RESULTS: Overall, 472 patients (236 intervention cases, 236 matched controls) were included in the study. Of the 236 patients receiving a FAME deprescribing plan, 147 had recommendations approved by prescriber and patient. In the intention-to-treat analysis, the 1-year change in modified DBI was -0.15 (95% CI -0.23, -0.08) in the intervention cohort and -0.11 (-0.21, -0.00) in the matched control cohort (p = 0.47). The odds of increasing DBI by a clinically important threshold of 0.5 was significantly lower in the FAME cohort (OR 0.37, 0.21, 0.66). Fall-related acute events occurred in 6.3% of patients in the intervention group versus 11.0% in control patients over a one-year period (p = 0.10). CONCLUSIONS: The program was associated with a significantly lower odds of further increasing FRID burden at 1 year compared to matched controls. An electronic case review and telephone counseling program has the potential to reduce drug-related falls in high-risk older adults.

Deprescribing medications among patients with multiple prescribers: A socioecological model.

Deprescribing is the intentional dose reduction or discontinuation of a medication. The development of deprescribing interventions should take into consideration important organizational, interprofessional, and patient-specific barriers that can be further complicated by the presence of multiple prescribers involved in a patient's care. Patients who receive care from an increasing number of prescribers may experience disruptions in the timely transfer of relevant healthcare information, increasing the risk of exposure to drug-drug interactions and other medication-related problems. Furthermore, the fragmentation of healthcare information across health systems can contribute to the refilling of discontinued medications, reducing the effectiveness of deprescribing interventions. Thus, deprescribing interventions must carefully consider the unique characteristics of patients and their prescribers to ensure interventions are successfully implemented. In this special article, an international working group of physicians, pharmacists, nurses, epidemiologists, and researchers from the United States Deprescribing Research Network (USDeN) developed a socioecological model to understand how multiple prescribers may influence the implementation of a deprescribing intervention at the individual, interpersonal, organizational, and societal level. This manuscript also includes a description of the concept of multiple prescribers and outlines a research agenda for future investigations to consider. The information contained in this manuscript should be used as a framework for future deprescribing interventions to carefully consider how multiple prescribers can influence the successful implementation of the service and ensure the intervention is as effective as possible.

Potential Clinical and Economic Outcomes of Over-the-Counter Hearing Aids in the US.

Importance: Over-the-counter (OTC) hearing aids are now available in the US; however, their clinical and economic outcomes are unknown. Objective: To project the clinical and economic outcomes of traditional hearing aid provision compared with OTC hearing aid provision. Design, Setting, and Participants: This cost-effectiveness analysis used a previously validated decision model of hearing loss (HL) to simulate US adults aged 40 years and older across their lifetime in US primary care offices who experienced yearly probabilities of acquiring HL (0.1%-10.4%), worsening of their HL, and traditional hearing aid uptake (0.5%-8.1%/y at a fixed uptake cost of $3690) and utility benefits (0.11 additional utils/y). For OTC hearing aid provision, persons with perceived mild to moderate HL experienced increased OTC hearing aid uptake (1%-16%/y) based on estimates of time to first HL diagnosis. In the base case, OTC hearing aid utility benefits ranged from 0.05 to 0.11 additional utils/y (45%-100% of traditional hearing aids), and costs were $200 to $1400 (5%-38% of traditional hearing aids). Distributions were assigned to parameters to conduct probabilistic uncertainty analysis. Intervention: Provision of OTC hearing aids, at increased uptake rates, across a range of effectiveness and costs. Main Outcomes and Measures: Lifetime undiscounted and discounted (3%/y) costs and quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). Results: Traditional hearing aid provision resulted in 18.162 QALYs, compared with 18.162 to 18.186 for OTC hearing aids varying with OTC hearing aid utility benefit (45%-100% that of traditional hearing aids). Provision of OTC hearing aids was associated with greater lifetime discounted costs by $70 to $200 along with OTC device cost ($200-$1000/pair; 5%-38% traditional hearing aid cost) due to increased hearing aid uptake. Provision of OTC hearing aids was considered cost-effective (ICER<$100 000/QALY) if the OTC utility benefit was 0.06 or greater (55% of the traditional hearing aid effectiveness). In probabilistic uncertainty analysis, OTC hearing aid provision was cost-effective in 53% of simulations. Conclusions and Relevance: In this cost-effectiveness analysis, provision of OTC hearing aids was associated with greater uptake of hearing intervention and was cost-effective over a range of prices so long as OTC hearing aids were greater than 55% as beneficial to patient quality of life as traditional hearing aids.

Machine learning functional impairment classification with electronic health record data.

BACKGROUND: Poor functional status is a key marker of morbidity, yet is not routinely captured in clinical encounters. We developed and evaluated the accuracy of a machine learning algorithm that leveraged electronic health record (EHR) data to provide a scalable process for identification of functional impairment. METHODS: We identified a cohort of patients with an electronically captured screening measure of functional status (Older Americans Resources and Services ADL/IADL) between 2018 and 2020 (N = 6484). Patients were classified using unsupervised learning K means and t-distributed Stochastic Neighbor Embedding into normal function (NF), mild to moderate functional impairment (MFI), and severe functional impairment (SFI) states. Using 11 EHR clinical variable domains (832 variable input features), we trained an Extreme Gradient Boosting supervised machine learning algorithm to distinguish functional status states, and measured prediction accuracies. Data were randomly split into training (80%) and test (20%) sets. The SHapley Additive Explanations (SHAP) feature importance analysis was used to list the EHR features in rank order of their contribution to the outcome. RESULTS: Median age was 75.3 years, 62% female, 60% White. Patients were classified as 53% NF (n = 3453), 30% MFI (n = 1947), and 17% SFI (n = 1084). Summary of model performance for identifying functional status state (NF, MFI, SFI) was AUROC (area under the receiving operating characteristic curve) 0.92, 0.89, and 0.87, respectively. Age, falls, hospitalization, home health use, labs (e.g., albumin), comorbidities (e.g., dementia, heart failure, chronic kidney disease, chronic pain), and social determinants of health (e.g., alcohol use) were highly ranked features in predicting functional status states. CONCLUSION: A machine learning algorithm run on EHR clinical data has potential utility for differentiating functional status in the clinical setting. Through further validation and refinement, such algorithms can complement traditional screening methods and result in a population-based strategy for identifying patients with poor functional status who need additional health resources.

State of research in adult Hospital Medicine: Updated results of a national survey and longitudinal analysis of national data.

We sought to understand the current state of research in adult Hospital Medicine by repeating a 2018 survey of leaders in Hospital Medicine with changes to improve the response rate of surveyed programs. We also analyzed the public sources of federal research funding and MEDLINE-indexed publications from 2010 through 2019 among members of the Society of Hospital Medicine (SHM). Of the 102 contacted leaders of Hospital Medicine groups across the country, 49 responded, for a total response rate of 48%. Among the 3397 faculty members represented in responding programs, 72 (2%) of faculty were identified as conducting research for more than 50% of their time. Respondents noted difficulties at every stage of the research development pipeline, from a lack of mentors to running a fellowship program to a lack of applicants seeking further research training. Improvements to our research training pipeline will be essential to the long-term improvement of our profession.

Predictors of Non-Transport for Older Adult EMS Patients Encountered for Falls.

BACKGROUND: Emergency medical services (EMS) encounters for falls among older adults have been linked to poor outcomes when the patient is not transported by EMS to a hospital. However, little is known regarding characteristics of this patient population. Our primary objective was to describe characteristics associated with non-transport among older adult EMS patients encountered for falls. METHODS: We performed a national retrospective cross-sectional study of 9-1-1 patient contacts from the 2019 ESO Data Collaborative. We included patients who had 9-1-1 encounters for ground-level falls and were aged 60 years or older. Patients residing in congregate living facilities, interfacility transports, cardiac arrests, and suspected drowning patients were excluded. Potential predictors of non-transport included patient demographics, initial vital signs, who requested 9-1-1 service, incident location, alcohol/substance use, and urbanicity. We used multivariable logistic regression to determine associations between non-transport and potential predictors. RESULTS: We identified 195,204 EMS encounters for older adults who fell in 2019, including 27,563 (14.1%) non-transports. Most patients were female (62.4%), non-Hispanic White (85.4%), and fell at a home or residence (80.4%). Greater odds of non-transport were identified among males (OR 1.37, 95% CI 1.32-1.42) and Hispanic/Latino patients (OR 1.24, 95% CI 1.14-1.35). Older age was associated with greater odds of non-transport compared to patients aged 60-69 years (70-79 [OR 1.42, 95% CI 1.35-1.49], 80-89 [OR 1.51, 95% CI 1.42-1.59], ≥90 [OR 1.45, 95% CI 1.35-1.55]). Patients residing in Census tracts with larger percentages of the population living in poverty had lower odds of non-transport compared to those in areas with ≤5% in poverty (6-15% poverty [OR 0.82, 95% CI 0.78-0.84), 15-25% poverty [OR 0.78, 95% CI 0.73-0.82], and >25% poverty [OR 0.78, 95% CI 0.72-0.84]). CONCLUSION: Males, older age groups, and Hispanic/Latino patients had higher odds of non-transport among this population of community-dwelling adults age 60 or greater. These findings may inform development of future targeted falls-related mobile integrated health or community paramedic services and referrals to community intervention programs. Future work is needed to understand underlying patient and clinician perspectives driving non-transport decisions among these patients to better equip EMS clinicians with tools and information on tailored risk/benefit discussions.

Model-Projected Cost-Effectiveness of Adult Hearing Screening in the USA.

BACKGROUND: While 60% of older adults have hearing loss (HL), the majority have never had their hearing tested. OBJECTIVE: We sought to estimate long-term clinical and economic effects of alternative adult hearing screening schedules in the USA. DESIGN: Model-based cost-effectiveness analysis simulating Current Detection (CD) and linkage of persons with HL to hearing healthcare, compared to alternative screening schedules varying by age at first screen (45 to 75 years) and screening frequency (every 1 or 5 years). Simulated persons experience yearly age- and sex-specific probabilities of acquiring HL, and subsequent hearing aid uptake (0.5-8%/year) and discontinuation (13-4%). Quality-adjusted life-years (QALYs) were estimated according to hearing level and treatment status. Costs from a health system perspective include screening ($30-120; 2020 USD), HL diagnosis ($300), and hearing aid devices ($3690 year 1, $910/subsequent year). Data sources were published estimates from NHANES and clinical trials of adult hearing screening. PARTICIPANTS: Forty-year-old persons in US primary care across their lifetime. INTERVENTION: Alternative screening schedules that increase baseline probabilities of hearing aid uptake (base-case 1.62-fold; range 1.05-2.25-fold). MAIN MEASURES: Lifetime undiscounted and discounted (3%/year) costs and QALYs and incremental cost-effectiveness ratios (ICERs). KEY RESULTS: CD resulted in 1.20 average person-years of hearing aid use compared to 1.27-1.68 with the screening schedules. Lifetime total per-person undiscounted costs were $3300 for CD and ranged from $3630 for 5-yearly screening beginning at age 75 to $6490 for yearly screening beginning at age 45. In cost-effectiveness analysis, yearly screening beginning at ages 75, 65, and 55 years had ICERs of $39,100/QALY, $48,900/QALY, and $96,900/QALY, respectively. Results were most sensitive to variations in hearing aid utility benefit and screening effectiveness. LIMITATION: Input uncertainty around screening effectiveness. CONCLUSIONS: We project that yearly hearing screening beginning at age 55+ is cost-effective by US standards.

Estimated Monetary Value of Future Research Clarifying Uncertainties Around the Optimal Adult Hearing Screening Schedule.

Importance: Adult hearing screening is not routinely performed, and most individuals with hearing loss (HL) have never had their hearing tested as adults. Objective: To project the monetary value of future research clarifying uncertainties around the optimal adult hearing screening schedule. Design, Setting, and Participants: In this economic evaluation, a validated decision model of HL (DeciBHAL-US: Decision model of the Burden of Hearing loss Across the Lifespan) was used to simulate current detection and treatment of HL vs hearing screening schedules. Key model inputs included HL incidence (0.06%-10.42%/y), hearing aid uptake (0.54%-8.14%/y), screening effectiveness (1.62 × hearing aid uptake), utility benefits of hearing aids (+0.11), and hearing aid device costs ($3690). Distributions to model parameters for probabilistic uncertainty analysis were assigned. The expected value of perfect information (EVPI) and expected value of partial perfect information (EVPPI) using a willingness to pay of $100 000 per quality-adjusted life-year (QALY) was estimated. The EVPI and EVPPI estimate the upper bound of the dollar value of future research. This study was based on 40-year-old persons over their remaining lifetimes in a US primary care setting. Exposures: Screening schedules beginning at ages 45, 55, 65, and 75 years, and frequencies of every 1 or 5 years. Main Outcomes and Measures: The main outcomes were QALYs and costs (2020 US dollars) from a health system perspective. Results: The average incremental cost-effectiveness ratio for yearly screening beginning at ages 55 to 75 years ranged from $39 200 to $80 200/QALY. Yearly screening beginning at age 55 years was the optimal screening schedule in 38% of probabilistic uncertainty analysis simulations. The population EVPI, or value of reducing all uncertainty, was $8.2 to $12.6 billion varying with willingness to pay and the EVPPI, or value of reducing all screening effectiveness uncertainty, was $2.4 billion. Conclusions and Relevance: In this economic evaluation of US adult hearing screening, large uncertainty around the optimal adult hearing screening schedule was identified. Future research on hearing screening has a high potential value so is likely justified.

Potential Targets for Deprescribing in Medically Complex Older Adults with Suspected Cognitive Impairment.

Deprescribing may be particularly beneficial in patients with medical complexity and suspected cognitive impairment (CI). We describe central nervous system (CNS) medication use and side effects in this population and explore the relationship between anticholinergic burden and sleep. We conducted a cross-sectional analysis of baseline data from a pilot randomized-controlled trial in older adult veterans with medical complexity (Care Assessment Need score > 90), and suspected CI (Telephone Interview for Cognitive Status score 20−31). CNS medication classes included antipsychotics, benzodiazepines, H2-receptor antagonists, hypnotics, opioids, and skeletal muscle relaxants. We also coded anticholinergic-active medications according to their Anticholinergic Cognitive Burden (ACB) score. Other measures included self-reported medication side effects and the Pittsburgh Sleep Quality Index (PSQI). ACB association with sleep (PSQI) was examined using adjusted linear regression. In this sample (N = 40), the mean number of prescribed CNS medications was 2.2 (SD 1.5), 65% experienced ≥ 1 side effect, and 50% had an ACB score ≥ 3 (high anticholinergic exposure). The ACB score ≥ 3 compared to ACB < 3 was not significantly associated with PSQI scores (avg diff in score = −0.1, 95% CI −2.1, 1.8). Although results did not demonstrate a clear relationship with worsened sleep, significant side effects and anticholinergic burden support the deprescribing need in this population.

Utilization of a National Writing Challenge to Promote Scholarly Work: A Pilot Study.

Background Hospitalists value mentorship and scholarly work, yet often struggle to find time and mentors amid busy clinical workloads. Objective To help catalyze writing for hospitalists nationally, we created a Writing Challenge, where we asked hospitalists to commit to the goal of writing 400 words a day, four days a week, for four weeks. Methods Prospective, programmatic evaluation with daily logs followed by a survey at the completion of the project. The four-week Writing Challenge occurred between June 7 and July 5, 2021. Email invitations to participate in the challenge were disseminated to peer networks, and the challenge was promoted using social media. Participants agreed to attempt to write 400 words per day, four days per week, for four weeks. Results Seventy-four individuals from 28 institutions registered for the Writing Challenge, with 36 (49%) participating in the challenge by logging their writing. Participants wrote an average of 4,372 +/- 4,324 words during the challenge. Sixty-eight percent of the participants reported that their amount of writing increased during the challenge and 50% of the participants stated they planned to publish their work, though many participants (46%) reported struggling to write each day. Conclusions The Writing Challenge is one way to generate increased writing and may result in increased scholarly output for academic hospitalists.

Implementation of a telehealth videoconference to improve hospital-to-skilled nursing care transitions: Preliminary data.

BACKGROUND: Transition-related patient safety errors are high among patients discharged from hospitals to skilled nursing facilities (SNFs), and interventions are needed to improve communication between hospitals and SNF providers. Our objective was to describe the implementation of a pilot telehealth videoconference program modeled after Extension for Community Health Outcomes-Care Transitions and examine patient safety errors and readmissions. METHODS: A multidisciplinary telehealth videoconference program was implemented at two academic hospitals for patients discharged to participating SNFs. Process measures, patient safety errors, and hospital readmissions were evaluated retrospectively for patients discussed at weekly conferences between July 2019-January 2020. Results were mapped to the constructs of the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) model. Descriptive statistics were reported for the conference process measures, patient and index hospitalization characteristics, and patient safety errors. The primary clinical outcome was all-cause 30-day readmissions. An intention-to-treat (ITT) analysis was conducted using logistic regression models fit to compare the probability of 30-day hospital readmission in patients discharged to participating SNFs across 7 months prior to after telehealth project implementation. RESULTS: There were 263 patients (67% of eligible patients) discussed during 26 telehealth videoconferences. Mean discussion time per patient was 7.7 min and median prep time per patient was 24.2 min for the hospital pharmacist and 10.3 min for the hospital clinician. A total of 327 patient safety errors were uncovered, mostly related to communication (54%) and medications (43%). Differences in slopes (program period vs. pre-implementation) of the probability of readmission across the two time periods were not statistically significant (OR 0.95, [95% CI 0.75, 1.19]). CONCLUSIONS: A pilot care innovations telehealth videoconference between hospital-based and SNF provider teams was successfully implemented within a large health system and enhanced care transitions by optimizing error-prone transitions. Future work is needed to understand process flow within nursing homes and its impact on clinical outcomes.

Impact of Hearing Aid Use on Falls and Falls-Related Injury: Results From the Health and Retirement Study.

OBJECTIVES: Falls are considered a significant public health issue and falls risk increases with age. There are many age-related physiologic changes that occur that increase postural instability and the risk for falls (i.e., age-related sensory declines in vision, vestibular, somatosensation, age-related orthopedic changes, and polypharmacy). Hearing loss has been shown to be an independent risk factor for falls. The primary objective of this study was to determine if hearing aid use modified (reduced) the association between self-reported hearing status and falls or falls-related injury. We hypothesized that hearing aid use would reduce the impact of hearing loss on the odds of falling and falls-related injury. If hearing aid users have reduced odds of falling compared with nonhearing aid users, then that would have an important implications for falls prevention healthcare. DESIGN: Data were drawn from the 2004-2016 surveys of the Health and Retirement Study (HRS). A generalized estimating equation approach was used to fit logistic regression models to determine whether or not hearing aid use modifies the odds of falling and falls injury associated with self-reported hearing status. RESULTS: A total of 17,923 individuals were grouped based on a self-reported history of falls. Self-reported hearing status was significantly associated with odds of falling and with falls-related injury when controlling for demographic factors and important health characteristics. Hearing aid use was included as an interaction in the fully-adjusted models and the results showed that there was no difference in the association between hearing aid users and nonusers for either falls or falls-related injury. CONCLUSIONS: The results of the present study show that when examining self-reported hearing status in a longitudinal sample, hearing aid use does not impact the association between self-reported hearing status and the odds of falls or falls-related injury.

Evaluating the Association Between Hearing Loss and Falls in Adults With Vestibular Dysfunction or Nonvestibular Dizziness.

OBJECTIVES: Although emerging evidence suggests that hearing loss (HL) is an independent risk factor for falls, it is unclear how HL may impact falls risk in adults with vestibular dysfunction and nonvestibular dizziness. The purpose of this study was to characterize the impact of HL on falls in patients with vestibular dysfunction and nonvestibular dizziness relative to a group of patients without dizziness. In addition, this study aimed to evaluate whether there was an interactive effect between HL and vestibular dysfunction or nonvestibular dizziness on the odds of falling. DESIGN: The authors conducted a retrospective cross-sectional study of 2,750 adult patients with dizziness evaluated at a tertiary care center vestibular clinic between June 1, 2015, and October 7, 2020. Only patients with available self-reported falls status, as extracted from the electronic medical record, were included. Patients were classified into the following diagnostic groups based on rotary chair testing and videonystagmography: benign paroxysmal positional vertigo (BPPV, n = 255), unilateral vestibular hypofunction (UVH, n = 456), bilateral vestibular hypofunction (BVH, n = 38), central dysfunction (n = 208), multiple diagnoses (n = 109), and dizzy, nonvestibular (n = 1,389). A control group of patients without dizziness (n = 295) was identified by a random sample of audiology patients. Degree of HL was characterized by the 4-frequency pure tone average (PTA) (0.5, 1, 2, and 4 kHz) of the better hearing ear. Demographic variables, comorbidities, cognitive impairment status, and falls-associated medications were extracted from the electronic medical record and included as covariates during analysis. Potential associations between PTA and falls status and possible interactions between diagnostic group and PTA were explored using multivariate logistic regression. RESULTS: The BVH and central dysfunction groups had the highest rates of self-reported falls at 26.3% and 26.9%, respectively. The control group had the lowest rate of self-reported falls at 6.4%. With the exception of the multiple diagnoses group, all diagnostic groups had elevated odds of falling compared with the control group, when adjusting for demographics, comorbidities, cognitive impairment status, and falls-associated medications. There was no significant association between degree of HL and falls status (odds ratio [OR] = 1.02; 95% confidence interval [CI] = 0.93, 1.11; p = 0.713) when adjusting for diagnostic group and all other covariates. Furthermore, there were no significant interactions between diagnostic group and degree of HL on the odds of falling. CONCLUSIONS: These results indicate that HL was not associated with falls in patients with vestibular dysfunction or nonvestibular dizziness, while adjusting for demographics, comorbidities, and falls-associated medications. There was no significant interactive effect observed between HL and vestibular dysfunction or nonvestibular dizziness on the odds of falling. As previously reported, vestibular dysfunction and nonvestibular dizziness were independently associated with falls relative to a group of patients without dizziness. A population-based study utilizing more robust falls data is needed to explore a potential association between HL and falls in those with vestibular dysfunction.

Towards "mobility is medicine": Socioecological factors and hospital mobility in older adults.

BACKGROUND: Understanding the factors that influence hospital mobility, especially in the context of a heightened focus on falls prevention, is needed to improve care. OBJECTIVE: This qualitative study uses a socioecological framework to explore factors that influence hospital mobility in older adults. DESIGN: Qualitative research PARTICIPANTS: Semi-structured interviews and focus groups were conducted with medically-ill hospitalized older adults (n = 19) and providers (hospitalists, nurses, and physical and occupational therapists (n = 48) at two hospitals associated with an academic health system. APPROACH: Interview and focus group guides included questions on perceived need for mobility, communication about mobility, hospital mobility culture, and awareness of patients' walking activity. Data were analyzed thematically and mapped onto the constructs of the socioecological model. KEY RESULTS: A consistent theme among patients and providers was that "mobility is medicine." Categories of factors reported to influence hospital walking activity included intrapersonal factors (patients' health status, fear of falls), interpersonal factors (patient-provider communication about mobility), organizational factors (clarity about provider roles and responsibilities, knowledge of safe patient handling, reliance on physical therapy for mobility), and environmental factors (falls as a never event, patient geographical locations on hospital units). Several of these factors were identified as potentially modifiable targets for intervention. Patients and providers offered recommendations for improving awareness of patient's ambulatory activity, assigning roles and responsibility for mobility, and enhancing education and communication between patients and providers across disciplines. CONCLUSION: Patients and providers identified salient factors for future early mobility initiatives targeting hospitalized older adults. Consideration of these factors across all stages of intervention development and implementation will enhance impact and sustainability.