Journal of the American Geriatrics Society最新文献

The Inflation Reduction Act (IRA) of 2022 introduced major changes in the Part D benefit that aim to improve medication access and correct several of the financial misalignments in the current Part D benefit. The changes address financial obligations of Medicare beneficiaries, the federal government, Part D plan sponsors (i.e., insurance companies), and drug manufacturers. The changes include new brand and biologic manufacturer obligations to beneficiaries eligible for the low-income subsidy. Effects on the drug supply chain and stakeholder behaviors remain to be seen but current financial arrangements inform likely responses. Currently, the Pharmacy Benefit Managers (PBMs) nestled between the plans, drug manufacturers, and pharmacies heavily influence manufacturers' list prices and squeeze community pharmacies. With the IRA restructuring of Part D, plans are likely to interject more administrative obstacles before beneficiaries can obtain higher-cost therapies, while drug manufacturers might alter their patient assistance programs. Manufacturers have already begun to change their assistance programs at many safety net pharmacies. Many Medicare beneficiaries who relied on these deeply discounted medications will face significant late enrollment penalties if they do enroll in Part D plans, creating a major barrier to participation. Providers and policymakers should understand the Part D changes and leverage the skills of pharmacists to support community and team-based care that improves access to medications and ensures that medications are doing more good than harm.

Background: An emergency department (ED) visit or hospitalization provides an opportunity to identify elder mistreatment and initiate intervention, but this seldom occurs. To address this, we developed the Vulnerable Elder Protection Team (VEPT), a novel interdisciplinary consultation service. We explored the long-term trajectories of patients receiving VEPT evaluation and intervention.

Methods: We followed up at multiple intervals for 12 months older adults seen by VEPT from 9/1/2020-3/27/2023 with high or moderate concern for mistreatment who were discharged to the community, an elder abuse shelter, or rehabilitation facilities. We collected information through telephone calls to the older adult and others involved. We also analyzed separately cases in which the patient re-presented to the ED/hospital with VEPT consultation during the follow-up period.

Results: A total of 157 older adults met criteria for follow-up, and 30 of these (16.4%) died within 12 months. At 1 month, elder mistreatment was no longer occurring in 47.5% and still occurring but reduced in 20.3%, with 29.7% having no contact with the perpetrator and 17.8% having reduced contact. At 12 months, elder mistreatment was no longer occurring in 60.9% and still occurring but reduced in 14.5%, with 34.8% having no contact with the perpetrator and 17.4% having reduced contact. During the 12-month follow-up period, 16 (10.2%) patients re-presented to the ED with VEPT consultation, with 12 having persistent concern for ongoing elder mistreatment. Reasons included older adults/caregivers not accepting intervention or being willing to separate as well as VEPT reliance on community-based agencies and programs after discharge.

Conclusions: We observed improved post-discharge safety for elder mistreatment victims who engaged with the VEPT program, with this increased safety durable over 1 year. Re-presentations highlighted the complexity of elder mistreatment intervention. Overall, these findings demonstrate the potential value of an ED/hospital-based elder mistreatment response team, a promising new geriatric care model.

Background: Healthcare systems need to address the high healthcare use of frail older adults. The Geriatric Services Hub (GSH) is a novel program in Singapore that delivers frailty screening, comprehensive geriatric assessment and coordinated care for community-dwelling older persons with bio-psycho-social needs. We aimed to evaluate the effects of the GSH on healthcare use.

Methods: We compared healthcare utilization of 634 GSH participants with 634 unique propensity score-matched non-GSH community-dwelling older adults at 12 months before and after GSH enrolment. Baseline matching covariates included demographics, socioeconomic status, disease burden, calendar quarter of enrolment, and past healthcare utilization. We did exact matching on frailty categories (Clinical Frailty Score (CFS) score 4, 5, and 6-7). Difference-in-differences technique was used to derive effect estimates.

Results: After propensity score matching, baseline covariates were adequately balanced. Healthcare utilization declined in both groups after GSH enrolment. Relative to the comparators and after accounting for pre-enrolment differences, participation in the GSH was associated with greater primary care (mean difference: 0.06, 95% CI-0.64 to 0.77) and specialist outpatient clinic visits (mean difference: 0.42, 95% CI -0.29 to 1.13), and fewer emergency department visits (mean difference: -0.18, 95% CI -0.69 to 0.34). However, these effects did not reach statistical significance. While number of hospitalizations did not differ between the groups, cumulative length of stay differed by 1.15 bed-days and was not statistically significant. No statistically significant differences were observed within CFS groups.

Conclusion: GSH was not associated with significant reductions in healthcare use in the first year of enrolment. Higher utilization of primary care and specialist outpatient clinic services could reflect the increased identification of care needs with the potential to reduce unnecessary healthcare use such as emergency department visits. Prospective studies with a longer follow-up would ascertain if the GSH translates to reduced healthcare utilization as hypothesized.

Background: Deprescribing antihypertensives is of growing interest in geriatric medicine, yet the impact on functional status is unknown. We emulated a target trial of deprescribing antihypertensive medications compared with continued use on functional status measured by activities of daily living (ADL) in a long-term care population.

Methods: We included 12,238 Veteran Affairs long-term care residents age 65+ who had a stay ≥ 12 weeks between 2006 and 2019. After 4+ weeks of stable antihypertensive medication use, residents were classified as either deprescribed antihypertensives (reduced ≥ 1 medication or ≥ 30% dose) or continued users. Residents were followed up for 2 years, or censored at discharge, admission to hospice, protocol deviation (per-protocol analysis only), or Sept 30, 2019. The outcome was ADL dependencies (scored 0-28; higher score = worse functionality), assessed approximately every 3 months. Our primary approach was to estimate per-protocol effects using linear mixed-effects regressions with inverse probability of treatment and censoring weighting, overall and stratified by dementia status. We estimated intention-to-treat effects as a secondary analysis.

Results: In long-term care residents, ADL scores worsened by a mean of 0.29 points (95%CI = 0.27, 0.31) per 3 months and antihypertensive deprescribing did not impact this worsening (difference between groups -0.04 points every 3 months, 95%CI = -0.15, 0.06). In the non-dementia subgroup, ADL worsened by 0.15 points (95%CI = 0.11, 0.19) every 3 months. However, residents who were deprescribed showed a slightly improved ADL score over time while the continued users showed ADL decline (difference between groups -0.23 points every 3 months, 95%CI = -0.43, -0.03). Deprescribing was not associated with ADL change in the dementia subgroup. The intention-to-treat results were not meaningfully different.

Conclusions: Antihypertensive deprescribing did not have a deleterious effect on functional status in long-term care residents with or without dementia. This may be reassuring to residents and clinicians who are considering antihypertensive medication reduction or discontinuation in long-term care settings.