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Quality Care for Pneumonia in the Elderly

Quality Care for Pneumonia in the Elderly

Adherence to recommended processes of care for patients hospitalized with pneumonia is publicly reported throughout the United States by CMS. Despite this reporting, little is known regarding whether more physicians are now performing these process measures and how they have impacted patient outcomes. Taking a Closer Look For a study published in JAMA Internal Medicine, Jonathan S. Lee, MD, and colleagues sought to describe the processes of care, mortality, and readmissions for elderly patients hospitalized with pneumonia. “The morbidity and mortality associated with pneumonia are especially prominent in the elderly,” says Dr. Lee. “We assessed how these patients are being cared for and whether there are steps that should be taken to potentially improve their mortality and readmissions rates.” The researchers conducted a retrospective analysis that involved more than 1.8 million Medicare fee-for-service patients aged 65 and older who were hospitalized for pneumonia in 2006 to 2010. Participants were eligible for at least one of seven inpatient processes of care that are tracked by CMS during their hospitalization, including: Influenza vaccination. Pneumococcal vaccination. Smoking cessation counseling. Performance of blood cultures before antibiotic therapy in the ED. Performance of blood cultures within 24 hours for ICU patients. Appropriate antibiotic selection. Antibiotic initiation within 6 hours. Based on the processes and outcomes of care, Dr. Lee and colleagues assessed the quality of care for pneumonia from 2006 to 2010. “By 2010, more than 92% of patients were receiving all of the processes of care for which they were eligible,” Dr. Lee says. “Mortality and readmission rates both decreased slightly during the study period. All seven processes of care were associated with...
Elective Major Orthopedic Surgery in Octogenarians

Elective Major Orthopedic Surgery in Octogenarians

By 2030, patients aged 85 and older are projected to account for 2.3% of the United States population, but this figure is expected to nearly double by 2050. There has also been an increasing trend in surgery being performed in the very elderly, but these patients have multiple risk factors that may increase their risk for adverse outcomes after surgery. As a result, there has been some controversy around performing elective surgeries to enhance quality of life (QOL) in this patient population. Typically, major orthopedic procedures like spinal fusion, total hip arthroplasty (THA), and total knee arthroplasty (TKA) are performed electively to alleviate pain and improve QOL. In a study published in the Journal of Bone & Joint Surgery, Hiroyuki Yoshihara, MD, PhD, and colleagues examined the trends and in-hospital outcomes of elective major orthopedic surgeries in patients who were at least 80 years old from 2000 to 2009 using data from the National Inpatient Sample on patients who underwent spinal fusion, THA, and TKA. The analysis included more than 70,000 spinal fusion cases, 233,000 THAs, and 417,000 TKAs. Complication and mortality rates were also compared for patients aged 80 and older with those aged 65 to 79. Incidence, Complications, & Mortality According to the study, there was an increasing trend in the age-adjusted incidence of spinal fusion, THA, and TKA in patients at least 80 years of age from 2000 to 2009. The age-adjusted incidence of spinal fusion increased from 40 to 101 per 100,000 people per year. For THA, the incidence increased from 181 to 257 per 100,000 people. For TKA, the incidence rose from 300 to...
Hip Fracture in Older Adults

Hip Fracture in Older Adults

As life expectancy continues to increase in the United States, the number of elderly people and those with chronic health conditions like osteo­porosis is also rising. The number of people older than 65 is expected to increase from 37.1 million to 77.2 million by the year 2040. With this aging trend, the incidence of hip fractures is also expected to increase. “The care of patients with hip fracture is improving, but it’s still a significant healthcare challenge that dramatically affects patients and their caregivers,” says W. Timothy Brox, MD. “These individuals are at greater risk of death after their hip fracture. They also experience other problems, including being unable to return to prior living circumstances, the need for increased super­vision, and decreased quality of life and mobility. Furthermore, hip fracture patients are at increased risk for secondary fractures.” Welcome Guidelines In 2014, the American Academy of Orthopaedic Surgeons (AAOS) released a clinical practice guideline (CPG) on managing hip fractures in the elderly. The guideline included many evidence-based recommen­dations throughout the continuum of care, ranging from preoperative treatments to post-discharge management. Some of the recommendations in the guidelines are aimed at reducing delirium in hip fracture patients, according to Dr. Brox, who chaired the AAOS CPG writing group. “Delirium is common among hip fracture patients,” he says. “Patients with postoperative delirium are less likely to return to their pre-injury levels of function. They’re also at higher risk for postoperative complications and are more frequently placed in nursing homes. The lower the incidence of post-fracture delirium, the more completely and effectively patients will recover.” Beyond delirium, the AAOS writing group gave...
Managing Older Patients With HIV

Managing Older Patients With HIV

In 2015, more than half of people with HIV in the U.S. will be aged 50 or older, according to Wayne McCormick, MD, MPH. “By 2025, the median age is projected to be 60 years old.” The aging HIV population has been due in large part to the success of antiretroviral therapy (ART). “Unfortunately, ART has many side effects that need to be taken into account when managing patients with HIV,” says Dr. McCormick. “Even with successful ART, patients with HIV still have an inflammatory infection. As they live longer, questions are raised about how to manage the comorbidities that are associated with HIV as well as those associated with aging.” A Helpful Initiative To address the unique issues of aging patients with HIV, members of the American Academy of HIV Medicine, the AIDS Community Research Initiative of America, and American Geriatrics Society created and launched www.hiv-age.org. The website was designed by these trusted organizations to allow for ongoing discussion about clinical care and research around HIV and aging. It is also intended to provide ways to share new and emerging infor­mation in this area. The HIV-Age website can help clinicians who seek best practices to care for older patients with HIV as well as interested patients, advocates, and researchers. “We wanted this information to be ‘live’ on the web so that it can be a living document that is changeable based on the ongoing conversations and emerging knowledge,” explains Dr. McCormick. “When research is published in hard copy, it can sometimes become fixed in time. Having a dedicated website allows us to quickly and easily update and correct...
Comprehensive Guidelines for Geriatric EDs

Comprehensive Guidelines for Geriatric EDs

The geriatric population in the United States is growing at a faster rate than the total population, and there will be an increasing need for healthcare among this patient group. “The aging population represents an unprecedented and overwhelming challenge to the healthcare system as a whole and to EDs specifically,” says Mark S. Rosenberg, DO, MBA, FACEP. Studies show that geriatric patients have 20% longer ED lengths of stay and use 50% more laboratory and imaging services than younger patients. Geriatric ED patients are also significantly more likely to require social services. It has been suggested that contemporary emergency medicine management models may be inadequate to care for the geriatric patient population. Published studies show that ED physicians often feel that they lack the proper training to manage geriatrics. “It’s challenging for ED physicians to manage older adults because they often have other medical comorbidities, take multiple medications, and present with complex physiologic changes,” Dr. Rosenberg says. “Programs specifically designed to address these concerns may substantially improve care. As the initial site of care for many health events, EDs have the opportunity to set the stage for subsequent care.” Geriatric EDs To enhance geriatric patient care in the emergency medicine setting, institutions throughout the U.S. have developed geriatric EDs, which are EDs dedicated to caring for older adults. The first such institutions appeared in the U.S. in 2008, but geriatric EDs have become increasingly common since that time. In response to the proliferation of geriatric EDs, the American College of Emergency Physicians (ACEP), the American Geriatrics Society, the Emergency Nurses Association, and the Society for Academic Emergency Medicine issued...
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