Journal of the American Geriatrics Society最新文献_第5页

Whether and how to store firearms in the home: Qualitative insights from care partner experiences in the Safety in Dementia Trial 是否以及如何在家中存放枪支：从痴呆症安全试验中护理伙伴的经验中获得的定性见解。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-10-25 DOI: 10.1111/jgs.19242

Christopher E. Knoepke PhD, MSW, Kayla Meza MPH, Jennifer D. Portz PhD, MSW, Megan L. Ranney MD, MPH, Stacy M. Fisher MD, Faris Omeragic BS, Emily Greenway MPH, Mirella Castaneda BS, Daniel D. Matlock MD, MPH, Marian E. Betz MD, MPH

Background

Most people with dementia (PWD) in the United States live in community settings supported by family and/or unpaid care partners. Firearms access is one of many decisions care partners navigate alongside PWD in efforts to prevent injuries and deaths. Conversations about firearms access are socially challenging, although specific challenges to be overcome have not been described.

Methods

As part of the larger Safety in Dementia Trial, we interviewed care partners about their views and experiences regarding firearms access in the home where the PWD resides. Interviewees were English-speaking adults (≥18 years) in the United States who are unpaid care partners of community-dwelling PWD. Responses to interview discussions related to (1) a desire for safety, and (2) fear of firearm violence was analyzed using a focusing process to categorize views into essential themes.

Results

Fifty care partners, who were primarily female (58%), White (66%), adult children (56%), and living in the same household (64%), participated in interviews between February 2023–February 2024. Dominant themes emerging from the focusing technique included (1) firearms as a necessary component of home safety; (2) fear of accidental/impulsive firearm violence; (3) observed risk and “near misses”; and (4) differing views on home firearms as a source of conflict. Thematic descriptions did not differ according to care partner's relationship to the PWD (adult child, spouse, other).

Conclusions

Considering whether and how to alter access to firearms where PWD reside can be difficult for care partners to navigate. Care partners expressed a desire to limit firearms access, but worried both about creating conflict with the PWD and the self-defense implications of making firearms inaccessible. Findings were similar across subsets of care partners indicating that standardized tools and messaging to care partners may be effective in promoting safety in homes with PWD.

背景：在美国，大多数痴呆症患者（PWD）都生活在由家人和/或无偿护理伙伴支持的社区环境中。在预防伤害和死亡的工作中，枪支使用权是护理伙伴与痴呆症患者共同做出的众多决定之一。关于使用枪支的对话在社会上具有挑战性，但具体需要克服的挑战尚未描述：作为 "痴呆症安全试验 "的一部分，我们采访了护理伙伴，了解他们对残疾人家中使用枪支的看法和经验。受访者是美国讲英语的成年人（≥18 岁），他们是居住在社区的残疾人的无偿护理伙伴。我们采用聚焦法分析了受访者对有关（1）渴望安全和（2）害怕枪支暴力的访谈讨论的回应，并将观点归类为基本主题：在 2023 年 2 月至 2024 年 2 月期间，50 名护理伙伴参加了访谈，他们主要是女性（58%）、白人（66%）、成年子女（56%）和生活在同一家庭（64%）。聚焦技术产生的主要议题包括：（1）枪支是家庭安全的必要组成部分；（2）对意外/冲动性枪支暴力的恐惧；（3）观察到的风险和 "险情"；以及（4）对家庭枪支作为冲突根源的不同看法。主题描述并不因护理伙伴与残疾人的关系（成年子女、配偶、其他）而有所不同：对于护理伙伴来说，考虑是否以及如何改变残疾人居住地的枪支获取途径可能会很困难。护理伙伴表达了限制接触枪支的愿望，但又担心与残疾人产生冲突，以及无法接触枪支对自卫的影响。不同护理伙伴子集的调查结果相似，这表明向护理伙伴提供标准化工具和信息可能会有效促进残疾人家庭的安全。

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引用次数: 0

Why do older adults stop cancer screening? Findings from the Medicare Current Beneficiary Survey 老年人为何停止癌症筛查？医疗保险当前受益人调查的结果。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-10-23 DOI: 10.1111/jgs.19239

Olivia H. Belliveau BA, Ilana B. Richman MD, MHS

Background

Prostate and breast cancer screening are prevalent among older adults, even among those unlikely to benefit. We aimed to evaluate why older adults stop cancer screening, including the role of physician recommendations.

Methods

We used nationally representative data from the 2019 Medicare Current Beneficiary Survey (MCBS). We included women aged 76 and older without a history of breast cancer and men aged 71 and older without a history of prostate cancer. The primary outcome was reason for discontinuing screening, categorized as follows: (1) physician recommendation against screening; (2) absence of a recommendation to screen; and (3) patient-driven reason, such as patient preferences or beliefs. We evaluated reasons for screening discontinuation by health status and educational attainment using age-stratified multinomial logistic regression.

Results

The sample included 7350 participants representing a weighted population of 22,498,715. Overall, 53% of women underwent screening mammography in the past year or intended to continue screening. Among those who stopped screening, 5% reported a recommendation to stop screening from their doctor, 48% reported no recommendation, and 32% reported a patient-driven reason for cessation. Findings did not differ by educational attainment or health status, including among the oldest patients. For men, 61% were screened with PSA in the past year or intended to continue. Among those who stopped, 3% reported a recommendation against screening, 54% reported no recommendation, and 27% reported a patient-driven reason for cessation. Men with higher educational attainment were more likely to report that their physician recommended against screening (4% vs. 1%, p = 0.01) and that their doctor did not recommend screening (58% vs. 47%, p = 0.01). Reasons for screening cessation did not differ by health status, including among the oldest patients.

Conclusions

Cancer screening remains common, even among those with limited potential for benefit, but discussions around screening cessation are rare. Improving communication between patients and physicians may improve screening decision quality.

背景：前列腺癌和乳腺癌筛查在老年人中很普遍，甚至在那些不太可能受益的老年人中也是如此。我们旨在评估老年人停止癌症筛查的原因，包括医生建议的作用：我们使用了 2019 年医疗保险当前受益人调查 (MCBS) 中具有全国代表性的数据。我们纳入了 76 岁及以上无乳腺癌病史的女性和 71 岁及以上无前列腺癌病史的男性。主要结果是停止筛查的原因，分类如下：(1)医生建议不要进行筛查；(2)没有建议进行筛查；(3)患者驱动的原因，如患者的偏好或信仰。我们使用年龄分层多叉逻辑回归法评估了不同健康状况和教育程度的人停止筛查的原因：样本包括 7350 名参与者，加权人口为 22,498,715 人。总体而言，53%的妇女在过去一年中接受了乳腺放射摄影筛查或打算继续接受筛查。在停止筛查的妇女中，5%的人表示医生建议她们停止筛查，48%的人表示没有医生建议，32%的人表示停止筛查的原因是由患者决定的。不同教育程度或健康状况的患者，包括年龄最大的患者，在筛查结果上没有差异。61%的男性患者在过去一年中接受了 PSA 筛查或打算继续接受筛查。在停止筛查的患者中，3%的人表示收到了反对筛查的建议，54%的人表示没有收到建议，27%的人表示停止筛查的原因是由患者决定的。教育程度较高的男性更有可能报告其医生建议不要进行筛查（4% 对 1%，P = 0.01），也更有可能报告其医生不建议进行筛查（58% 对 47%，P = 0.01）。停止筛查的原因不因健康状况而异，包括年龄最大的患者：结论：癌症筛查仍然很普遍，即使在潜在获益有限的人群中也是如此，但围绕停止筛查的讨论却很少见。改善患者与医生之间的沟通可提高筛查决策的质量。

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引用次数: 0

Differences in setting of initial dementia diagnosis among fee-for-service Medicare beneficiaries 付费医疗保险受益人初次诊断痴呆症的背景差异。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-10-22 DOI: 10.1111/jgs.19236

Elizabeth M. White APRN, PhD, Thomas Bayer MD, Cyrus M. Kosar PhD, Christopher M. Santostefano RN, MPH, Ulrike Muench RN, PhD, Hyesung Oh MPH, MBA, Emily A. Gadbois PhD, Pedro L. Gozalo PhD, Momotazur Rahman PhD

Background

Accurate and timely diagnosis of dementia is necessary to allow affected individuals to make informed decisions and access appropriate resources. When dementia goes undetected until a hospitalization or nursing home stay, this could reflect delayed diagnosis or misdiagnosis, and may reflect underlying disparities in healthcare access.

Methods

In this retrospective cohort study, we used 2012–2020 Medicare claims and other administrative data to examine variation in setting of dementia diagnosis among fee-for-service Medicare beneficiaries with an initial claims-based dementia diagnosis in 2016. We used multinomial logistic regression to evaluate the association of person and geographic factors with diagnosis location, and Cox proportional hazards regression to examine 4-year survival relative to diagnosis location.

Results

Among 754,204 Medicare beneficiaries newly diagnosed with dementia in 2016, 60.3% were diagnosed in the community, 17.2% in hospitals, and 22.5% in nursing homes. Adjusted 4-year survival rates were significantly lower among those diagnosed in hospitals [−16.1 percentage points (95% CI: −17.0, −15.1)] and nursing homes [−16.8 percentage points (95% CI: −17.7, −15.9)], compared to those diagnosed in the community. Community-diagnosed beneficiaries were more often female, younger, Asian or Pacific Islander, Native American or Alaskan Native, Hispanic, had fewer baseline hospitalizations and higher homecare use, and resided in wealthier ZIP codes. Rural beneficiaries were more likely to be diagnosed in hospitals.

Conclusions

Many older adults are diagnosed with dementia in a hospital or nursing home. These individuals have significantly lower survival than those diagnosed in the community, which may indicate diagnosis during an acute illness or care transition, or at a later disease stage, all of which are suboptimal. These results highlight the need for improved dementia screening in the general population, particularly for individuals in rural areas and communities with higher social deprivation.

背景：准确及时地诊断痴呆症对患者做出明智决策和获得适当资源十分必要。如果痴呆症直到住院或入住疗养院时才被发现，这可能反映出诊断延迟或误诊，也可能反映出医疗保健服务的潜在差异：在这项回顾性队列研究中，我们使用了 2012-2020 年的医疗保险报销单和其他管理数据，研究了 2016 年初次报销单诊断为痴呆症的付费医疗保险受益人中痴呆症诊断环境的变化。我们使用多叉逻辑回归评估了个人和地理因素与诊断地点的关联，并使用 Cox 比例危险回归检验了与诊断地点相关的 4 年生存率：在2016年新确诊为痴呆症的754204名医疗保险受益人中，60.3%在社区确诊，17.2%在医院确诊，22.5%在疗养院确诊。与在社区确诊的患者相比，在医院确诊的患者[-16.1个百分点（95% CI：-17.0，-15.1）]和疗养院确诊的患者[-16.8个百分点（95% CI：-17.7，-15.9）]调整后的4年生存率明显较低。社区确诊的受益人多为女性、年轻、亚裔或太平洋岛民、美国原住民或阿拉斯加原住民、西班牙裔、基线住院次数较少、家庭护理使用率较高、居住在较富裕的邮政编码内。农村受益人更有可能在医院确诊：结论：许多老年人是在医院或养老院被诊断出患有痴呆症的。这些人的存活率明显低于在社区确诊的患者，这可能表明他们是在急性疾病或护理过渡期间或疾病晚期确诊的，所有这些情况都不理想。这些结果凸显了在普通人群中改进痴呆症筛查的必要性，尤其是对农村地区和社会贫困程度较高的社区的痴呆症患者而言。

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引用次数: 0

Capacity assessment for euthanasia in dementia: A qualitative study of 60 Dutch cases 痴呆症患者安乐死的能力评估：对 60 个荷兰案例的定性研究。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-10-21 DOI: 10.1111/jgs.19218

Arne van den Bosch BSc, Radboud M. Marijnissen MD, PhD, Denise J. C. Hanssen PhD, Richard C. Oude Voshaar MD, PhD

Background

The number of patients with dementia who are granted euthanasia or assisted suicide (EAS) increases yearly in the Netherlands. By law, patients need to be decisionally competent or have an advance directive. Assessment of decisional capacity is challenging as dementia progressively affects cognitive performance. We aimed to assess qualitatively which factors, and how, influence the judgment of decisional capacity in EAS cases with dementia.

Methods

We performed a qualitative study of 60 dementia EAS case summaries published by the Dutch regional euthanasia review committees between 2012 and 2021. Included reports were evaluated using the grounded theory approach. All quotes related to decisional capacity were coded independently by two researchers and compared in an iterative process to formulate an overarching framework on the assessment of decisional capacity. We selected 20 patients who had an advance directive and were judged to be decisionally compromised, as well as a selection of 40 EAS cases judged to be decisionally competent, half of which also had an advance directive (purposive sampling).

Results

Decisional capacity was present in every case report. Predefined, external criteria were rarely described explicitly, but physicians indirectly referred to the (cognitive) criteria set by Appelbaum and Grisso. Whether the thresholds for these dimensional criteria were met was influenced by six supporting factors (level of communication, psychiatric comorbidity, personality, presence of an advance directive, consistency of the request, and, finally, the patient–physician relationship) that also directly contributed to the judgment of capacity. The involved physicians and executed investigations were the two contextual factors providing a background.

Conclusions

Decisional capacity regarding euthanasia is a multidimensional construct, often implicitly assessed and influenced by supporting and contextual factors. The subjectivity of the final judgment poses ethical and legal issues and argues for continuous quality improvement processes.

背景：在荷兰，获准安乐死或协助自杀（EAS）的痴呆症患者人数逐年增加。根据法律规定，患者需要具备决策能力或预先指示。由于痴呆症会逐渐影响患者的认知能力，因此评估患者的决策能力具有挑战性。我们旨在定性评估哪些因素以及如何影响对痴呆症 EAS 病例决策能力的判断：我们对荷兰地区安乐死审查委员会在 2012 年至 2021 年间发布的 60 份痴呆症安乐死案例摘要进行了定性研究。我们采用基础理论方法对纳入的报告进行了评估。所有与决定能力相关的引文均由两名研究人员独立编码，并通过反复比较，最终制定出一个评估决定能力的总体框架。我们选取了 20 名有预先指示且被判定为决策能力受损的患者，并选取了 40 个被判定为有决策能力的 EAS 病例，其中一半也有预先指示（目的性抽样）：结果：每份病例报告中都存在决策能力问题。预设的外部标准很少被明确描述，但医生间接提到了阿贝尔鲍姆（Appelbaum）和格里斯索（Grisso）制定的（认知）标准。是否符合这些维度标准的阈值受到六个辅助因素的影响（沟通水平、精神疾病合并症、性格、是否有预先指示、请求的一致性，以及最后的医患关系），这些因素也直接影响了对行为能力的判断。参与调查的医生和已执行的调查是两个背景因素：关于安乐死的决定能力是一个多维度的概念，通常是隐性评估，并受到支持因素和背景因素的影响。最终判断的主观性带来了伦理和法律问题，因此需要不断改进质量。

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引用次数: 0

Lessons from the Department of Veterans Affairs: A continuum of age-friendly care for older adults 退伍军人事务部的经验教训：为老年人提供持续的老年友好护理。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-10-18 DOI: 10.1111/jgs.19228

Kimberly A. Wozneak MS, Shivani K. Jindal MD, MPH, Shannon Munro PhD, APRN, BC, NP, Courtney A. Huhn MD, Tonya Page DNP, RN, MHA, Thomas E. Edes MD, MS, Scotte R. Hartronft MD, MBA

With almost 90% of Americans expressing a desire to age in place in their home, many health systems and communities are challenged to provide the right resources, at the right time, to support What Matters to older adults. In the Department of Veterans Affairs (VA), approximately 50% of Veterans enrolled in VA health care are aged 65 and older, driving an imperative to provide timely, Age-Friendly care through a broad continuum of services. VA has taken a multifaceted approach to shift Long-Term Services and Supports to promote aging in place through innovation pilots, expansion of Home and Community Based Services (HCBS) and adoption of Age-Friendly Health Systems (AFHS) practices [or “framework”]. VA is spreading geriatrics knowledge throughout the clinician and trainee workforce, improving skills and practices across all disciplines and care settings. The framework of AFHS creates a shared language to support transitions across ambulatory, hospital, emergency department, home care, and nursing home settings. Through these efforts, VA is reimagining geriatrics, providing an example of the type of care all older adults want and deserve. Since March 2020, 375 care settings across 132/139 (95%) VA parent facilities have earned AFHS recognition. By incorporating AFHS into the infrastructure of the healthcare system, clinicians are prepared to address What Matters across clinical settings and address common geriatric syndromes. Leaders in a variety of health systems can learn from VA efforts to provide a continuum of Age-Friendly programs and services that promote independence, function, well-being and aging in place.

近 90% 的美国人表示希望在家中安享晚年，许多医疗系统和社区都面临着在适当的时间提供适当的资源以支持老年人的重要事项的挑战。在退伍军人事务部（VA），约 50%接受退伍军人医疗保健服务的退伍军人年龄在 65 岁及以上，因此必须通过广泛的连续性服务提供及时、适合老年人的医疗保健服务。退伍军人事务部采取了多方面的方法来转变长期服务和支持，通过创新试点、扩大家庭和社区服务（HCBS）以及采用老龄友好医疗系统（AFHS）实践[或 "框架"]来促进居家养老。退伍军人事务部正在整个临床医生和受训人员队伍中传播老年医学知识，提高所有学科和护理环境的技能和实践。AFHS 框架创造了一种共享语言，以支持门诊、医院、急诊科、家庭护理和疗养院环境之间的过渡。通过这些努力，退伍军人事务部正在重新构想老年医学，为所有老年人想要和应该得到的护理类型提供了一个范例。自 2020 年 3 月以来，132/139（95%）个退伍军人事务部上级机构中的 375 个护理机构获得了 AFHS 认证。通过将 AFHS 纳入医疗保健系统的基础设施，临床医生已准备好在各种临床环境中处理 "重要事项"，并应对常见的老年综合症。各种医疗系统的领导者都可以从退伍军人事务部的努力中汲取经验，以提供一系列 "爱老计划 "和服务，促进独立、功能、幸福和居家养老。

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引用次数: 0

Predictors of advance care planning in 11 high-income nations 11 个高收入国家预先护理规划的预测因素。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-10-17 DOI: 10.1111/jgs.19226

Preshit N. Ambade DrPH, Zachary T. Hoffman MS, Kaamya Mehra BS/MD(c), Neil J. MacKinnon PhD

Background

Elderly population is increasing in high-income countries. For instance, by 2050, 21.4% of the United States population is expected to be 65+, thus making advance care planning (ACP) increasingly important. We aim to identify predictors of ACP completion in 11 high-income countries and explore relationships between ACP and utilization factors.

Method

Using the 2021 International Health Policy (IHP) survey data, we assessed the relationship between sociodemographic factors, healthcare utilization, and ACP. The primary outcome variable was a composite of three ACP activities. A generalized linear mixed model (GLMM) was used to identify predictors of ACP completion.

Results

Analyses included 18,677 older adults who answered at least one ACP question. Only 5126 (27.4%) reported completion of three ACP activities. Germany (64.7%) showed the highest completion rates, while Sweden (5.0%) and France (5.0%) showed the lowest completion rates. Predictors of ACP completion identified in the GLMM were: increasing age (incidence rate ratio [IRR] range between 1.2 and 1.5), completion of high school education or more (IRR: 1.1, 95% CI: 1.1–1.1), higher income (IRR: 1.1, 95% CI: 1.1–1.2), presence of two or more health conditions (IRR: 1.1, 95% CI: 1.0–1.1), hospital stay in the past 2 years (IRR: 1.1, 95% CI: 1.1–1.1), and access to quality primary care (IRR: 1.0, 95% CI: 1.0–1.1). Male gender (IRR: 0.9, 95% CI: 0.8–0.9) had a negative association with ACP activity completion.

Conclusion

Several patient-specific and health system utilization factors were identified as predictors of ACP activity completion, which clinicians and policymakers could use to enhance ACP completion.

背景：在高收入国家，老年人口正在不断增加。例如，到 2050 年，美国 21.4% 的人口预计将达到 65 岁以上，这使得预先护理计划（ACP）变得越来越重要。我们旨在确定 11 个高收入国家完成 ACP 的预测因素，并探讨 ACP 与利用因素之间的关系：利用 2021 年国际卫生政策（IHP）调查数据，我们评估了社会人口因素、医疗保健利用率和 ACP 之间的关系。主要结果变量是 ACP 三项活动的综合结果。我们使用广义线性混合模型（GLMM）来确定完成 ACP 的预测因素：分析包括 18677 名至少回答了一个 ACP 问题的老年人。只有 5126 人（27.4%）报告完成了三项 ACP 活动。德国（64.7%）的完成率最高，而瑞典（5.0%）和法国（5.0%）的完成率最低。在 GLMM 中确定的完成 ACP 的预测因素有：年龄增加（发病率比 [IRR] 范围在 1.2 和 1.5 之间）、完成高中或以上教育（IRR：1.1，95% CI：1.1-1.1）、收入增加（IRR：1.1，95% CI：1.1-1.2）、有两种或两种以上健康状况（IRR：1.1，95% CI：1.0-1.1）、过去 2 年住院（IRR：1.1，95% CI：1.1-1.1）以及获得优质初级医疗服务（IRR：1.0，95% CI：1.0-1.1）。男性性别（IRR：0.9，95% CI：0.8-0.9）与完成 ACP 活动呈负相关：结论：几项患者特异性因素和医疗系统使用因素被认为是 ACP 活动完成度的预测因素，临床医生和政策制定者可以利用这些因素来提高 ACP 活动的完成度。

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引用次数: 0

A public health/hospital partnership to improve Emergency Department transitions of care for vulnerable older adults 公共卫生与医院合作，改善急诊科对弱势老年人的过渡护理。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-10-17 DOI: 10.1111/jgs.19227

Lauren T. Southerland MD, MPH, Carolyn Dixon MSSA, mSAC, LSW, Shameka Turner, Kalih M. West BSW, Tameka Hairston RN, Tony Rosen MD, MPH, Caroline Rankin MPH

Background

Community-dwelling older adults are at high risk for unmet social service needs. We describe a novel partnership embedding county services case managers in the Emergency Department (ED) to connect older adults to community services alongside their medical care.

Methods

Setting: A medium-sized urban ED with 55,000 patient visits a year. Intervention: Case managers from the Franklin County, Ohio Office on Aging (OA) were embedded within the ED. The OA team worked with the ED social work team to identify community-dwelling older patients, perform an in-person intake assessment, and initiate needed community services (including home-delivered meals, emergency response systems, house repairs, and transportation). Program logic model and development are reported in detail.

Results

From June to December 2023, there were 7284 ED visits for adults ≥60 years old. Referrals to the OA case manager ranged from 1 to 13 per day. The OA case managers performed 252 full intake assessments on unique patients. The population was 51% men. Only 11% (n = 28) were currently connected to OA services, and of those already connected 29% (n = 8) needed increased services. Of the remaining unconnected patients (n = 224), 8% (n = 20) were not county residents and the OA team connected them with other county OAs. Half 53% (n = 120) were accepting of services and had services from the OA or other community health programs initiated during the ED visit. The OA team made three new Adult Protective Services referrals and one referral to the long-term care ombudsman. The program did not increase ED length of stay or hospital admission rates.

Conclusions

Embedding county service enrollment within a community ED is a cost neutral intervention that reached a population without previous services. Future plans include expansion of the program and evaluation of the program's ability to detect elder mistreatment and self-neglect.

背景：居住在社区的老年人是社会服务需求得不到满足的高危人群。我们介绍了一种新颖的合作方式，即在急诊科（ED）中设置县级服务机构的个案经理，在为老年人提供医疗服务的同时，将他们与社区服务联系起来：环境：干预措施：干预措施：俄亥俄州富兰克林县老龄化办公室（OA）的个案经理被派驻到急诊科。OA 团队与急诊室社工团队合作，识别居住在社区的老年患者，进行上门入院评估，并启动所需的社区服务（包括送餐上门、应急响应系统、房屋维修和交通）。详细报告了计划逻辑模型和发展情况：从 2023 年 6 月到 12 月，≥60 岁的成年人共接受了 7284 次急诊室就诊。转介给 OA 个案经理的人数从每天 1 人到 13 人不等。OA 个案经理共对 252 名患者进行了全面的入院评估。其中 51% 为男性。目前只有 11%（n = 28）的患者获得了 OA 服务，而在已经获得 OA 服务的患者中，29%（n = 8）的患者需要更多服务。在其余未连接的患者（n = 224）中，8%（n = 20）不是本县居民，OA 小组将他们连接到了本县其他 OA。半数 53%（n = 120）的患者接受了服务，并在急诊室就诊期间接受了 OA 或其他社区健康计划提供的服务。OA 小组新转介了 3 名成人保护服务人员和 1 名长期护理监察员。该计划并未增加急诊室的住院时间或入院率：在社区急诊室内嵌入县级服务登记是一项成本中立的干预措施，可惠及以前未接受过服务的人群。未来的计划包括扩展该计划并评估该计划检测虐待老人和自我忽视的能力。

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引用次数: 0

Experiences of older surgical patients and care partners during COVID-19: Lessons for future care 老年手术患者和护理伙伴在 COVID-19 期间的经历：对未来护理的启示。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-10-16 DOI: 10.1111/jgs.19212

Mark Iskandar BA, C. Ann Vitous MPH, Lillian Min MD, MSHS, Pasithorn A. Suwanabol MD, MS, Alexandra Norcott MD, MS

<p>The COVID-19 pandemic introduced unique challenges for patients undergoing elective major surgery, including scheduling delays, a transition to virtual care, and frequent policy changes (e.g., visitor restrictions, discharge processes).<span><sup>1, 2</sup></span> These challenges disproportionally affected older adults (aged ≥65 years), who are more medically complex, less apt to use technology, and often involve friends and family members (i.e., care partners) in their surgical care.<span><sup>3, 4</sup></span> The dismantling of routine care processes and support systems provided an opportunity to evaluate perceptions and values of older surgical patients and their care partners both separately and as a patient–caregiver <i>dyad</i>.<span><sup>5</sup></span> Using preoperative and postoperative patient and care partner interviews, we sought to understand dyad experiences during major surgery to inform potential strategies to improve surgical care.</p><p>We used convenience sampling to identify dyads undergoing elective colorectal surgery (<i>n</i> = 10) from July 2020 to July 2021.<span><sup>6</sup></span> Participants were diverse across race, patient-care–partner relationship, and cognitive status as assessed using the Telephone Montreal Cognitive Assessment with scores <18 indicating possible impairment (Table 1).<span><sup>7</sup></span> Verbal informed consent was obtained. Using Zoom, we interviewed dyad members separately before and after surgery. Interview domains centered on preparations, knowledge, and challenges. Interviews were audio recorded and transcribed. Using an inductive thematic analysis approach, two researchers independently coded transcripts without a preexisting coding schema. Following each interview, the full team met to review the codes and refine the codebook. Interviews continued until reaching data saturation. A final coding schema was then applied, and the full team analyzed the codes in segments for overarching themes. The University of Michigan Medicine Institutional Review Board approved this study.</p><p>Interviews revealed four dominant themes impacting surgical experiences (Table 2). (1) <i>Surgery was perceived as non-elective</i>: Due to discomfort or a perceived lack of alternative options, dyads viewed the surgery as urgently needed to maintain or improve their quality of life. Uncertainty around scheduling and delays led to distress among dyads. (2) <i>In-person meetings were valued</i>: Meetings in-person, especially with the surgeon, were critical for establishing trust. Additionally, virtual care was sometimes perceived as an indicator of lower surgical complexity and contributed to additional distress when recovery was prolonged. (3) <i>Importance of care partner involvement</i>: Patients felt the emotional, physical, and informational support of their care partner contributed to the success of their surgery. Care partner involvement also improved perceived patient recall and adherence to dir

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引用次数: 0

Comparison of targeted web-based advertising versus traditional methods for recruiting older adults into clinical trials 在招募老年人参与临床试验方面，基于网络的定向广告与传统方法的比较。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-10-16 DOI: 10.1111/jgs.19225

Kathryn Baldyga BA, Ike Iloputaife BS, George Taffet MD, Nicole LaGanke BSc, Brad Manor PhD, Lewis A. Lipsitz MD, Courtney L. Millar PhD

Background

Recruiting older adults into clinical trials can be particularly challenging. Our objective was to determine if targeted web-based advertising is an effective recruitment strategy.

Methods

We compared the recruitment rates of traditional and targeted web-based methods for three representative clinical trials involving older adults. All studies utilized traditional recruitment methods initially, but shifted toward primarily targeted web-based advertising after experiencing slow recruitment rates.

Results

We found that web-based advertising reached more individuals compared to traditional methods. Compared to traditional methods, web-based methods also had at least twice the rate of expressed interest, completion of telephone and in-person screening, eligibility, and enrollment. Additionally, the proportion of individuals excluded after the telephone screening did not differ according to whether targeted web-based advertising (STAMINA: 51%; Berries and Steps: 62%; ISTIM: 20%) or traditional methods (STAMINA: 48%; Berries and Steps: 69%; ISTIM: 23%) were used within each study. Those recruited using web-based advertisements tended to be younger compared to traditional methods, but were similar in racial distribution and education.

Conclusion

Targeted web-based advertisements may be more effective in recruiting older adults for clinical trials at a faster rate than traditional recruitment methods, but need further evaluation of compatible study designs, potential population bias, and cost-effectiveness.

背景：招募老年人参与临床试验尤其具有挑战性。我们的目的是确定有针对性的网络广告是否是一种有效的招募策略：我们比较了三项有代表性的涉及老年人的临床试验中传统方法和有针对性的网络方法的招募率。所有研究最初都采用了传统的招募方法，但在经历了缓慢的招募率之后，主要转向了有针对性的网络广告：结果：我们发现，与传统方法相比，网络广告的受众更多。与传统方法相比，基于网络的方法在表达兴趣、完成电话和面对面筛选、资格审查和注册方面的比率也至少是传统方法的两倍。此外，电话筛查后被排除在外的人员比例并没有因每项研究中使用了有针对性的网络广告（STAMINA：51%；Berry and Steps：62%；ISTIM：20%）还是传统方法（STAMINA：48%；Berry and Steps：69%；ISTIM：23%）而有所不同。与传统方法相比，使用网络广告招募到的人往往更年轻，但在种族分布和教育程度方面相似：与传统招募方法相比，有针对性的网络广告在招募老年人参与临床试验方面可能更有效，但还需要进一步评估研究设计的兼容性、潜在的人群偏差以及成本效益。

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引用次数: 0

Physician-reported barriers and facilitators to thyroid hormone deprescribing in older adults 医生报告的老年人停用甲状腺激素的障碍和促进因素。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-10-11 DOI: 10.1111/jgs.19219

Brandon Moretti MD, Rachel Livecchi MD, Stephanie R. Taylor BS, Susan C. Pitt MD, Brittany L. Gay BS, Megan R. Haymart MD, Arti Bhan MD, Jennifer Perkins MD, Maria Papaleontiou MD

Background

Thyroid hormone is one of the most commonly prescribed medications in the United States. Misuse of and overtreatment with thyroid hormone is common in older adults and can lead to cardiovascular and skeletal adverse events. Even though deprescribing can reduce inappropriate care, no studies have yet explored specific barriers and facilitators to guide thyroid hormone deprescribing in older adults (defined as discontinuation of thyroid hormone when initiated without an appropriate indication or dose reduction in those overtreated).

Methods

We conducted semi-structured interviews with 19 endocrinologists, geriatricians, and primary care physicians who prescribe thyroid hormone. Interviews were completed between July 2020 and December 2021 via two-way video conferencing. We used both an inductive and deductive content analysis guided by the Theoretical Domains Framework to evaluate transcribed and coded participant responses. Thematic analysis characterized themes related to barriers and facilitators to thyroid hormone deprescribing practices in older adults.

Results

The most commonly reported barriers to thyroid hormone deprescribing were related to patient-level factors, followed by physician- and system-level factors. Patient factors included patients' perceived need for thyroid hormone use and patient anxiety/concerns about potential side effects related to thyroid hormone dose reduction, patient lack of knowledge, and misinformation regarding deprescribing. Physician- and system-level barriers included clinic visit time constraints, physician inertia, physician lack of knowledge about deprescribing, perceived lack of sufficient patient follow-up, and electronic health record limitations. The most prominent physician-reported facilitators to thyroid hormone deprescribing were effective physician-to-patient communication, and positive physician–patient relationship, including patients' trust in their treating physician.

Conclusion

Barriers and facilitators to thyroid hormone deprescribing in older adults were reported at multiple levels including patient-, physician-, and system-level factors. Interventions to improve thyroid hormone deprescribing in older adults should aim to improve patient education and expectations, increase multidisciplinary physician awareness, and overcome physician inertia.

背景：甲状腺激素是美国最常用的处方药之一：甲状腺激素是美国最常用的处方药之一。甲状腺激素的滥用和过度治疗在老年人中很常见，可导致心血管和骨骼不良事件。尽管停用甲状腺激素可以减少不适当的治疗，但目前还没有研究探讨指导老年人停用甲状腺激素的具体障碍和促进因素（指在没有适当适应症的情况下停用甲状腺激素，或在过度治疗的情况下减少剂量）：我们对 19 名开具甲状腺激素处方的内分泌科医生、老年病科医生和初级保健医生进行了半结构化访谈。访谈于 2020 年 7 月至 2021 年 12 月期间通过双向视频会议完成。在理论领域框架的指导下，我们采用了归纳和演绎内容分析的方法来评估转录和编码的参与者回答。主题分析描述了与老年人甲状腺激素处方障碍和促进因素相关的主题：最常报告的甲状腺激素处方障碍与患者层面的因素有关，其次是医生和系统层面的因素。患者因素包括患者对使用甲状腺激素的需求感知、患者对甲状腺激素剂量减少可能产生的副作用的焦虑/担忧、患者缺乏相关知识以及有关停药的错误信息。医生和系统层面的障碍包括门诊时间限制、医生惰性、医生对减量用药缺乏了解、认为缺乏足够的患者随访以及电子健康记录的限制。在医生的报告中，甲状腺激素处方最主要的促进因素是医生与患者之间的有效沟通以及积极的医患关系，包括患者对主治医生的信任：老年人停用甲状腺激素的障碍和促进因素涉及多个层面，包括患者、医生和系统层面的因素。改善老年人甲状腺激素处方的干预措施应着眼于改善对患者的教育和期望，提高多学科医生的认识，并克服医生的惰性。

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引用次数: 0