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Showing posts from November, 2011

Too Much of A Good Thing

There is an estimated 6.7 million emergency hospitalizations every year in the US. One out of every 67 of these hospitalizations is due to an adverse drug event.

This is just one of the many interesting, although somewhat questionable points made by Daniel S. Budnitz and colleagues NEJM article titled “Emergency Hospitalizations for Adverse Drug Events in Older Americans”.   It's a compelling article that, in part, attempts to persuade the reader that most emergency hospitalizations for adverse drug events in older adults are not the result of physicians prescribing inappropriate medications like those listed in the Beers criteria.  Rather, the vast majority of hospitalizations are the result of a few commonly used medications, like warfarin, aspirin, plavix, and insulin.   This would be an interesting finding, if it were true.  Unfortunately, after reading this article I'm not sure it is.

Let's start with the primary outcomes that the authors looked at - "hospital…

The Hospital Disability Syndrome

Ken Covinsky previously posted on GeriPal a while back about the dangers of hospitalization in older adults.   Ken notes in that post that hospitalization is a vulnerable period leading to major new disability for many older adults.  More recently, Ken, GeriPal contributor Bree Johnston, and honorary GeriPal member Edgar Pierluissi authored a terrific article about hospital-associated disability in one of those pre-blogging era, old-fashioned periodicals...JAMA.

I'm not going to be able to sum up this meaty piece of scholarship in this post.  Let me say only that if you care for hospitalized older adults, and can only read one article that changes for the better how you care for them, this would be that article.   Let me relay some of the disruptive perspectives offered:

Move over traditional geriatric syndromes, and make way for the newcomer:  hospital-associated disability should be considered a geriatric syndrome (the "hospital disability syndrome").  Hospital-associa…

Quality Indicators Can Cause Harm in Older Patients: An Inconvenient Truth

Quality indicators are used to measure the quality of health care delivered to patients. Quality indicators are used extensively in the VA health system, and efforts are underway in Medicare to tie reimbursement levels to performance on quality indicators.

The motivations for using quality indicators are guided by the best of intentions. There are many problems with the quality of health care in the US, and quality indicators aim to improve this care. When put to their best use, quality indicators can improve care.

However, a recent commentary in JAMA from our UCSF colleagues, Geriatricians Sei Lee and Louise Walter raise serious concerns about unintended harms from quality indicators. Lee and Walter make a compelling arguement that quality indicators, when used indiscriminantly, can actually harm the quality of care provided to the older persons. This is particularly true for the most frail and vulnerable elders.

How is it possible that something designed to improve care can actuall…

What Drugs Should You Avoid In the Elderly: An Update on the Beers Criteria

Should you always avoid the use of metaclopromide in the elderly (I still use it in some circumstances)?  What about scopolamine - avoid always or consider for some instances like motion sickness?   And what about Megace - yet another drug to always avoid?

According to the new draft guidelines for the new AGS Updated Beers Criteria the answer for these questions and for many other medications is a clear "avoid".  Now is your chance though to both read these draft guidelines and to give your opinion before they are finalized (click here for the AGS site).

Why spend your time doing this?

It’s been two decades since the original Beers Criteria was published by the late Dr. Mark Beers. The original list comprised of drugs that were potentially inappropriate for elderly patients residing in nursing homes but have been subsequently revised to include elderly patients in all settings.

The drugs listed in the Beers Criteria have side effects that were thought to be far more harmfu…

Is hospital observation status the new pathway to frailty?

Have you noticed that your hospital is using the observation status more instead of simply admitting the patient? Three recent cases (from both a University hospital and a private hospital) have me interested in this question. It appears that this is a national trend which the American Medical Directors Association (AMDA) has apparently confirmed with the Centers for Medicare and Medicaid Services (CMS.) Per CMS the most recent data show claims for observation care rose from 828,000 in 2006 to more than 1.1 million in 2009. At the same time, claims for observation care lasting more than 48 hours tripled to 83,183.

Observation services include short-term treatment and tests provided in the hospital to help doctors determine if the patient should be admitted for inpatient treatment and whether the patient meets the admission criteria (eg. Interqual criteria). Medicare considers observation services outpatient care, which requires beneficiaries to cover a bigger share of drug costs and…

Geriatric Palliative Medical Education – Yeah! There is a place tostart from…

Have you heard of the Portal for Online Geriatric Education (POGOe)?

The Portal of Geriatric Online Education (http://www.POGOe.org/) is a free public repository of geriatric and palliative care educational materials (i.e. OSCEs, games, web-based modules, and lectures) developed by leading educators.Launched in 2004, the site boasts over 7,800 registered Users, visitors from over 150 countries, and contains over 650 educational materials.

Here are a couple key POGOe offerings that may interest our GeriPal community:




Lots of great NEW FORUMS! There’s one for geriatric fellowship directors (called ADGAP), GACA recipients, and one for both the AAHPM Geriatrics SIG & AGS Palliative Care SIG (it’s called the GeriPal forum). These forums provide a venue for educators around the world to participate in an online discussion with their peers. Come join the discussion!
Repository of Critically Acclaimed Papers (ReCAP) – An online journal club for geriatrics and palliative care fellows and facu…