Journal of the American Geriatrics Society
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Multicenter Study Observational Study
Aggressive Care near the End of Life for Cancer Patients in Medicare Accountable Care Organizations.
To compare aggressiveness of end-of-life (EoL) care for older cancer patients attributed to Medicare Shared Savings Programs with that for similar fee for service (FFS) beneficiaries not in an accountable care organization (ACO) and examine whether observed differences in EoL care utilization vary across markets that differ in ACO penetration. ⋯ Cancer patients attributed to ACOs had fewer repeated hospitalizations but more ICU admissions in the last month of life than non-ACO patients; they had similar rates of other measures of aggressive care at the EoL. This suggests opportunities for ACOs to improve EoL care for cancer patients. J Am Geriatr Soc 67:961-968, 2019.
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Randomized Controlled Trial Multicenter Study Pragmatic Clinical Trial
Pharmacological Management of Delirium in the Intensive Care Unit: A Randomized Pragmatic Clinical Trial.
Delirium in the intensive care units (ICUs) is prevalent, with both delirium duration and delirium severity associated with adverse outcomes. We designed a pragmatic trial to test the efficacy of a pharmacological management of delirium (PMD) bundle in improving delirium/coma-free days and reducing delirium severity among ICU patients. ⋯ Implementing the PMD bundle in the ICU did not reduce delirium duration or severity among critically ill patients.
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Multicenter Study
Post-Acute Care After Joint Replacement in Medicare's Bundled Payments for Care Improvement Initiative.
Bundled payments, in which services provided around a care episode are linked together, are being tested under Medicare's Bundled Payments for Care Improvement (BPCI) program. Reducing post-acute care (PAC) is critical under bundled payment, but little is known about whether this is done through provider selection or consolidation, and whether particular patterns of changes in PAC are associated with success under the program. ⋯ Reductions in spending under BPCI were driven by a shift from higher- to lower-cost discharge settings, and by shortening the duration of institutional PAC. Hospitals that reduced payments the most had the highest spending at baseline. J Am Geriatr Soc 67:1027-1035, 2019.
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As originally defined, the term "prescribing cascade" describes a sequence of events that begins when an adverse drug event (ADE) occurs, is misinterpreted as a new medical condition, and a subsequent drug is then inadvertently prescribed to treat the new condition. We refine the definition to encompass both recognized and unrecognized ADEs because they can both contribute to problematic prescribing practices. In addition, we discuss that although prescribing cascades are most commonly viewed as problematic, they may be appropriate and therapeutically beneficial in certain clinical situations. ⋯ Practical considerations are also presented to aid clinicians in preventing the propagation of problematic prescribing cascades within their clinical practice. Providing new perspectives on the scope and appropriateness of the prescribing cascade concept is an important step in describing clinically relevant cascades and in encouraging safe prescribing practices. J Am Geriatr Soc 67:1023-1026, 2019.
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As Americans live longer lives, we will see an increased demand for quality healthcare for older adults. Despite the growth in the number of older adults, there will be a decrease in the supply of a primary care physician workforce to provide adequately for their care and health needs. This article reviews the literature that explores ways to address the primary care workforce shortage in a community-based geriatric healthcare setting, with special attention to elevating the role of nurses and caregivers and shifting the way we think about delivery of care and end-of-life conversations and planning. ⋯ The many barriers to scaling and spreading models of care across varied settings include payment structures, lack of education and training among all stakeholders, and, at the top of the list, leadership resistance. We address these barriers and make recommendations for a path forward where healthcare providers, policymakers, patients, families, and everyone else involved can play a role in shaping the workforce caring for older adults. J Am Geriatr Soc 67:S400-S408, 2019.