Transcript Slide 1

Aging Q3
2011 Fall Faculty Retreat
Kiawah Island Golf Resort
Charleston, SC
Welcome to
Kiawah Island!
Aging Q3 Update
• Completed 9 ACOVEs to date
• In the middle of Pain Management
(ends Jan 20)
• 5 remain
– (Pressure Ulcers and Malnutrition are combined in
1 ACOVE)
Year 1:
2009-2010
1. Vision Loss
(May (June 2) – Sept 4)
Chair: Bill Moran, MD
Year 2:
4. Continuity of Care
2010-2011 (Mar 23-June 21)
Chair: Kim Davis, MD
Year 3:
8. End of Life Care
2011-2012 (Mar 17- Jul 5)
Chair: Paul Rousseau, MD
Year 4:
12. Depression
2012-2013
(Apr 12-July 19)
Chair: Bill Moran, MD
2. Falls and Mobility
(Sept 8 – Dec 14)
Chair: Kathy Wiley, MD
3. Dementia
(Dec 15 – Mar 22 2010)
Chair: Pam Pride, MD
5. Med Use & Safety
(Jun 22-Sep 21)
6. Screening/ Prev
Sep 28-Dec13
Chair: Amy Thompson,
PharmD
Chair: Elisha Brownfield,
MD
Chair: Neal Axon, MD
9. Osteoporosis
(July 21 – Oct 21)
10. Pain Management
(Oct 24-Jan 20, 2012)
11. Osteoarthritis
(Jan 23 – Apr 11, 2012)
Chair: Jay Brzezinski, MD Chair: Roger Kyle, MD
13. Urinary Incontinence
(July 20 – Oct 17)
14/15. Pressure
Ulcers/Malnutrition
(Oct 18 – Jan, 16 2013)
Chair: Fletcher Penney, MD Chair: Keri Holmes
Maybank, MD
7. Hospital Care/Transitions
(Dec 14- Mar 15, 2011)
Chair: Cathryn Caton, MD
16. Hearing Loss
(Jan 17 – Apr17, 2013)
Chair: Brad Keith, MD
Vision
ACOVE
Skill
Funduscopic
Exam
72/99
(73%)
Falls
Continuity Med Use &
Dementia
of Care
Safety
Timed Up &
Mini-Cog
Go
68/96
64/100
(70.8%)
(64%)
Primary
Care Med
Rec
80/97
(83%)
Med Rec
82/134
(61%)
Screening Hospital
End of Life Osteoporos
&
Care/ &
Care
is
Prevention Transitions
Commun.
Health
Discharge and Adv.
MaintenSummaries Directives
ance
70/96
Role Play
37/96
(73%)
60/96
(39%)
(62.5%)
FRAX
75/95
(79%)
≥75%
correct
answers
on Pretest
44/70
(63%)
11/67
(16.4%)
28/69
(40.6%)
35/76#
(46%)
20/72##
(27.8%)
12/76#
(15.8%)
27/72#
(37.5%)
37/67 ##
(55.2%)
27/92##
(29.3%)
≥75%
correct
answers
on PostTest
57/80
(71.2%)
34/69
(49.3%)
24/76
(31.6%)
22/72#
(30.6%)
24/76##
(35.5%)
29/72#
(40.3%)
38/67#
(56.7%)
37/72 ##
(51.4%)
48/77##
(62.3%)
p-value
p=0.2489
p<0.0001
p = 0.2558 p=0.0419
p=0.5174
p<0.0001
p=0.0163
p=0.6907
p<0.0001
86/100
(86%)
79/96
(82.3%)
82/134
(61.2%)
75/96
(78%)
80/96
(83%)
75/96
(78%)
80/95
(84.2%)
Resident’
83/99
s
(83.8%)
Detailed
# = ≥67% correct answer; # # = ≥80% correct answers
85/97
(87.6%)
Manuscripts and Publishing
• Patrick
Aging Q3 Manuscript Progress Table (11-30-11)
Lead Team
Title
Target Journals
Notes
Caton, Wiley, Moran ,Zapka
Teaching Falls Screening Evaluation
and Management in an IM Residency
Program
JAGS - Submitted
J Am Geriatr Soc. 2011 Aug 24. doi:
10.1111/j.1532-5415.2011.03555.x.
[Epub ahead of print] PMID: 21883104
[PubMed - as supplied by publisher]
Moran, Davis, Mauldin, et al
Where Are My Patients?
Southern Medical Journal - Submitted
Accepted
Brownfield, Mauldin,
Marsden, Iverson, Thompson
Immunizations Screening
AJIC - Submitted
Revisions
Moran ,Zapka, Iverson, Davis, Wiley,
Pride, Zhao
Innovation in Design and Evaluation
in Geriatric Education - Aging Q3
Academic Medicine - Submitted
Accepted - Revisions
Thompson, Freeland, Zhao, Mauldin,
Dizzy Making Drugs
Pharmacotherapy - Submitted
Revisions
Black, Mauldin, Moran, Caton
Estimated Cost Effectiveness of a
Resident Physician: Training Program
to Reduce Falls in Elderly
Innovations in Medical Education
JGIM - Submitted
In Review
JAGS – Submitted
In Review
Axon, Marsden, Mauldin, Iverson,
Thompson
A Curriculum with Individualized and
Team-based Feedback to Improve
Discharge Summary Quality
JAGS
In Progress
Thompson, Mauldin, Moran, Iverson
Medication Safety and the Elderly Aging Q3
Pharmacotherapy
In Progress
Iverson, Moran, Mauldin
Dementia
In Progress
Moran, Rousseau, Adler, Iverson,
Mauldin
End of Life – Advanced Directives
In Progress
Litvin, Davis, Moran, Zapka, Iverson,
Zhao
End of Life Care
ACOVE # 8
End of Life Care Working Group
Chair:
Paul Rousseau, MD
Working Group Members:
Leigh Vaughan MD
Rog Kyle MD
Elisha Brownfield MD
William P. Moran MD
Cara Litvin MD
Mary Adler RN
Lisa Roberge PA-C
Leah Clanton MD (Resident)
Amanada Overstreet MD (Resident)
Objectives
• How to estimate life expectancy
• How to communicate about Advanced Care
Directives
• How to lead a family meeting to discuss EOL
issues and/or deliver bad news
Interesting Results
• 57% (568/998) of patients seen were asked if they have
an ACD
• 23% of patients asked (131/568), DO have an ACD
– 51% (67/131) Resident knows their wishes
– 20% (26/131) Copy in the chart
• 77 % (437/568)of patients asked, don’t have ACD
– 49% (214/437) want to discuss ACD today
– 25% (111/437) want to discuss ACD at a follow up
visit
More!
• In 18% (99/537) of those patients for whom
the resident estimated life expectancy using
the Covinsky scale, the resident documented
the results did have an influence on the
clinical decision making.
Role Plays
60/96 (62.5%) of Residents participated in
at least 1 Role Play
Resident Reported Confident or Very Confident
Pre Test
Post Test
Discussing ACDs
58/96 (60%)
66/96 (69%)
Leading a Family
Meeting
44/96 (46%)
53/96 (55%)
Osteoporosis
ACOVE #9
Osteoporosis ACOVE Working Group
Working Group Chair:
Jay Brzezinski, MD
Working Group Members:
Pamela Pride MD
Leonard Lichtenstein MD
Amy Thompson PharmD
Brad Keith MD
Lara Hourani (Resident)
Tamela Sill, RN
Learning Objectives
• Who to refer for a DXA scan
• How/when to use a FRAX
• Treatment options for Osteoporosis
Have you ever calculated a FRAX
score?
A FRAX score is useful when:
90
80
Pre Test, N=92
70
Post Test, N=77
76.6% (59)
Percent, %
60
47.8% (44)
50
39.1% (36)
40
30
20.8% (16)
20
10
13.0% (12)
2.6% (2)
0
A. t score is greater than or
equal to -1.0
B. t score is less than -2.5
C. t score is between -1.0 and 2.4
A 70 year old female patient has a symptomatic
compression fracture of her thoracic spine.
Which of the following is true?
90
85.7% (66)
80
Pre Test, N=92
67.4% (62)
70
Post Test, N=77
Percent, %
60
50
40
30
20
10
14.1% (13)
13.0% (12)
3.9% (3)
5.4% (5)
3.9% (3)
6.5% (12)
0
A. Treatment with
B. Treat regardless of t- C. Treat only if FRAX D. Treatment depends
bisphosphonates should
score
score is greater than or on her other risk factors
occur if her t-score is <equal to 3%
2.0
The # of treated patients that are needed to
cause osteonecrosis of the jaw (NNH) is rouhgly:
90
83.1% (64)
80
Pre Test, N=92
70
Post Test, N=77
Percent, %
60
46.7% (43)
50
40
34.8% (32)
30
20
10
13.0% (12)
6.5% (5)
5.4% (5)
10.4% (8)
0
0
A. 100
B. 500
C. 1,000
D. 60,000
The # of treated osteoporosis patients that are
needed to prevent any fracture (NNT) is roughly:
70
60.9% (56)
Pre Test, N=92
62.3% (48)
60
Post Test, N=77
Percent, %
50
40
30
20
19.6% (18)
16.9% (13)
15.2% (14)
11.7% (9)
9.1% (7)
10
4.3% (4)
0
A. 10
B. 100
C. 500
D. 1,000
Which of the following is not a risk factor for
osteoporosis?
60
50
55.8% (43)
Pre Test, N=92
46.7% (43)
Post Test, N=77
Percent, %
40
30
19.6% (18)
20
10
20.7% (19)
14.3% (11)
8.7% (8)
18.2% (14)
6.5% (5)
5.2% (4)
4.3% (4)
0
A. Smoking
B. Rheumatoid
Arthritis
C. A parent with a D. Heavy alcohol E. Osteoarthritis of
hip fracture
use
hip or spine
On a scale of 1-5 with 1 being no confidence and 5
being very confident, rate your confidence in your
ability to decide ho to treat Osteoporosis in elderly
females:
40
38.0% (35)
37.0% (34)
36.4% (28)
35
Percent, %
31.2% (24)
30
Pre Test, N=92
25
Post Test, N=77
24.7% (19)
20
14.1% (13)
15
10
9.8% (9)
7.8% (6)
5
1.1% (1)
0
0
1
2
3
4
5
220/613=35.9% of patients seen (females 65+)
had a DEXA scan documented it was done or
referred
N=116 (done ‘yes’) + 104 (order ‘yes’)=220
D=613
81/95 = 85.3% of residents demonstrated
use of FRAX
158/170=92.9% of those patients who had
a frax calculated and documented, the
resident reported the results had
influence on clinical decision
Pain Management
ACOVE #10
Pain Management ACOVE Working
Group
Chair:
Rogers Kyle, MD
Working Group Members:
Deborah Dewaay MD
Amy Thompson PharmD
Jayne Quinn, RN
Objectives
• All patients 65+ presenting in the clinic will be
assessed for chronic and persistent pain.
• All hospitalized adult patients on Gen Med will
be assessed for uncontrolled pain, including
the use of PCA management for pain.
• All hospitalized adult patients on Gen Med on
opioid therapy for pain will be assessed for
efficacy and side effects.
Skills
• Manage PCA’s
• Conversion
• Pain assessment
Key Detailing Messages
• Opioid Use for Control of Pain
• Opioid Side Effects
• Non-Opioid Treatment Options
• Conversion
Pain ACOVE Participation Progress
• 6/24 = 25% of residents on IP rotation have
demonstrated how to properly read a PCA
• 27/94 = 29% of residents in OP have been
detailed
• 20/94 = 21.3% of residents in OP have
demonstrated pain assessment
NSAIDS are useful in the treatment of
moderate to severe pain.
A. True
B. False
100%
0%
A.
B.
A 70 year old woman has been taking 20 mgs of oxycodone
every 6 hours for two weeks for pain related to a pelvic
fracture. A reasonable next step in her pain management
would be to initiate a long acting
opioid such as:
100%
A.
B.
C.
D.
MSContin 60 mg BID
Fentanyl transdermal 75 mcg
Oxycontin 20 mg BID
Methadone 20 mg BID
0%
A.
B.
0%
C.
0%
D.
Which of the following medications might be useful in the
management of neuropathic pain in the elderly?
100%
A.
B.
C.
D.
E.
F.
NSAIDS
Anticonvulsants
Topical anesthetics
Antidepressants
B,C, and D
All of the above
A.
0%
0%
0%
0%
0%
B.
C.
D.
E.
F.
When prescribing pain medications, it is often useful to
combine an opioid with either acetaminophen or an NSAID.
100%
A. True
B. False
0%
A.
B.
A “Word” from our Residents!
Why “Assess Geriatric
Competencies?
• Drs. Clyburn and Keith
IM-FM Residents
Minimum Geriatric Competencies
•
•
•
•
•
•
•
Medication Management
Cognitive, Affective, and Behavioral Health
Complex or Chronic Illness(es) in Older Adults
Palliative and End of Life Care
Hospital Patient Safety
Transitions of Care
Ambulatory Care
Competencies and Curriculum
Development
Dr. Wong
ACGME Competencies
•
•
•
•
•
•
Patient Care
Medical Knowledge
Interpersonal and Communication Skills
Professionalism
Practice Based Learning
Systems Based Practice
Let’s Play a Game!
Drs. Caton and Thompson
2
M M“Madness
to Methods”
Amy Thompson
Cathryn Caton
• Medical College of Wisconsin
• Can be adapted to any learning task
• Engages the learner and their “competitive”
spirit
• Encourages Creativity
• Promotes transfer of behavior to real task
Upcoming ACOVEs
•
•
•
•
Osteoarthritis – Cathryn Caton, MD
Depression – Bill Moran, MD
Urinary Incontinence – Fletcher Penney, MD
Pressure Ulcers/Malnutrition – Keri HolmesMaybank, MD
• Hearing Loss – Brad Keith, MD
Osteoarthritis
ACOVE # 11
Chair:
Cathryn Caton, MD
Working Group Members:
Theresa Cuoco, MD
Pam Charity, MD
Keri Holmes-Maybank, MD
Don Fox, MD
Cara Litvin, MD
Amy Thompson, PharmD
Kathy Wiley, MD
Lynn Manfred, MD
Cheryl Lynch, MD
Ashley Morris (Med Student)
Objectives
• Perform & Document functional assessment
at the time of admission (H&P)
– Found under ROS section of the H&P
• Improve knowledge of treatment options
– Medications
– Physical Therapy
– Joint Replacement
Osteoarthritis
• Skill for outpatient?
– Joint injection labs
– Joint exams – knees, hips
– Tools for evaluating patients with osteoarthritis
Depression
ACOVE # 12
Chair:
Bill Moran, MD
Working Group Members:
Cara Litvin, MD
Delores Tetrault, MD
Cathryn Caton, MD
AmyThompson, PharmD
Brad Keith, MD
Temeia Martin, MD (Resident)
QI Residents
PHQ-2 Screen for Depression
PHQ-2 Score
Probability of
major
depressive
disorder (%)
Probability of
any depressive
disorder (%)
1
15.4
36.9
2
21.1
48.3
3
38.4
75.0
4
45.5
81.2
5
56.4
84.6
6
78.6
92.9
Over the past two weeks, how often have
you been bothered by any of the
following problems?
Little interest or pleasure in doing things.
0 = Not at all
1 = Several days
2 = More than half the days
3 = Nearly every day
Feeling down, depressed, or hopeless.
0 = Not at all
1 = Several days
2 = More than half the days
3 = Nearly every day
Thibault,
JM, Prasaad Steiner, RW. (2004) “Efficient Identification of Adults
with Depression and Dementia.” American Family Physician (70):6.
The Next Steps Grant
• Training of hospitalists and surgical and
medical specialists.
• Training physicians to learn to work optimally
with other disciplines.
Important Areas of Consideration
• Faculty recruitment and development
• Development of new educational techniques
and methodologies
– Methods to assess learners’ competencies in
these areas
• Existence or creation of infrastructure to
support proposed programs
Evaluations
• Survey in the envelope
• Green card in the box