The Training of Geriatricians in the United States: Three Decades of Progress

During the past 3 decades, significant progress has been made in preparing U.S. physicians to care for the growing elderly population. This paper reviews progress in training and certifying internists and family physicians in geriatric medicine. The establishment of the National Institute on Aging, a series of Institute of Medicine reports, Veterans Health Administration initiatives, and leadership and investment by the public sector and private foundations have supported the development of geriatric medicine training programs. In 1988, the Accreditation Council for Graduate Medical Education initially accredited 62 internal medicine (IM) and 16 family practice (FP) geriatric medicine fellowship programs. By academic year 2001–2002, 120 geriatric medicine fellowships were training 338 fellows. A recent survey of U.S. medical schools found a total of 869 full-time equivalent (FTE) geriatrics faculty members. Their geriatrics programs had a median of 5.0 FTE physician faculty members, with a range of 0 to 42. Recent surveys of IM and FP residency programs found 803 geriatrician faculty members teaching in IM residency programs (53% response rate) and 453 teaching in FP residency programs (75% response rate). From 1988 through 2002, 10,207 Certificates of Added Qualifications in Geriatrics were awarded. The distribution of these practicing geriatricians varied considerably by state, with the national average being 5.5 per 10,000 persons aged 75 and older. Individual state rates ranged from 2.2 to 15.9. Although geriatric medicine training has grown remarkably over the past 3 decades, this growth is still not producing the number of geriatricians needed to care for the growing elderly population. Thus, expanded investment in the training of geriatricians as faculty and practitioners is needed.     

Women’s Initiative for Nonsmoking (WINS) II: The intervention

Women’s Initiative for Nonsmoking (WINS) is a randomized clinical trial designed to test the efficacy of a nurse-managed smoking cessation and relapse prevention intervention designed specifically for women. The WINS intervention is rooted in social learning theory, specifically that of self-efficacy. It is a multimedia approach that provides education, counseling, and telephone follow-up that meet the smoking cessation intervention guidelines established by the Agency for Health Care Policy and Research. The WINS intervention has been successfully implemented in more than 140 women and has proven to be feasible and well accepted by both the women and their health care providers. Although the intervention in the protocol-driven randomized clinical trial was begun in the hospital, it is anticipated that nurses in any setting, inpatient or outpatient, who serve populations at risk for cardiovascular disease, peripheral vascular disease, lung cancer, or pulmonary disease could successfully provide the intervention. (Heart Lung^® 2000;29:438-45.)     

The Effects of Guided Care on the Perceived Quality of Health Care for Multi-morbid Older Persons: 18-Month Outcomes from a Cluster-Randomized Controlled Trial

BACKGROUND

The quality of health care for older Americans with chronic conditions is suboptimal.

OBJECTIVE

To evaluate the effects of “Guided Care” on patient-reported quality of chronic illness care.

DESIGN

Cluster-randomized controlled trial of Guided Care in 14 primary care teams.

PARTICIPANTS

Older patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC).

INTERVENTION

“Guided Care” is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2–5 physicians in providing comprehensive chronic care to 50–60 multi-morbid older patients.

MEASUREMENTS

Eighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care.

RESULTS

Of the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30–3.50, p = 0.003).

CONCLUSION

Guided Care improves self-reported quality of chronic health care for multi-morbid older persons.KEY WORDS: quality of care, chronic illness, older     

Evaluation of the Personal Impact Health Assessment Questionnaire (PI HAQ) to capture the impact of disability in osteoarthritis

Aim: Measuring facts about disability may not reflect their personal impact. An individualized values instrument has been used to weight difficulty in performing activities of daily living in rheumatoid arthritis, and calculate personal impact (Personal Impact Health Assessment Questionnaire; PI HAQ). This study aimed to evaluate the PI HAQ in osteoarthritis (OA). Study design: Study 1: 51 people with OA completed short and long versions of the value instrument at 0 and 1 week. Study 2: 116 people with OA completed the short value instrument, disability and psychological measures at 0 and 4 weeks. Results: Study 1: The eight‐category and 20‐item value instruments correlated well (r = 0.85) and scores differed by just 2.7%. The eight‐category instrument showed good internal consistency reliability (Cronbach's α = 0.85) and moderate one‐week test‐retest reliability (r = 0.68, Wilcoxon signed‐rank test p = 0.16, intra‐class correlation coefficient [ICC] 0.62). Study 2: Values for disability were not associated with disability severity or clinical status. After weighting disability by value, the resulting PI HAQ scores were significantly associated with dissatisfaction with disability, perceived increase in disability, poor clinical status and life dissatisfaction, and differed significantly between people with high and low clinical status (convergent and discriminant construct validity). There was moderate association with the disease repercussion profile disability subscale (r = 0.511; p < 0.001) (criterion validity). The PI HAQ was stable over four weeks (ICC 0.81). Conclusions: These studies provide an initial evaluation of an instrument to measure the personal impact of disability in people with OA, setting disability within a personal context. Further studies, including sensitivity to change, are required. Copyright © 2010 John Wiley & Sons, Ltd.     

Unique technique to relieve left ventricular assist device electromagnetic interference with an implantable cardioverter defibrillator

We introduced a simple technique to eliminate electromagnetic interference between a left ventricular assist device (LVAD) and an implantable cardioverter defibrillator (ICD). A 43-year-old male with heart failure and a reduced ejection fraction who had an ICD presented with decompensated heart failure and received an LVAD as a bridge to transplant. Remote monitoring showed persistent atrial fibrillation causing an inappropriate ICD shock leading to a decision to disable shock therapies. However, an in-office interrogation was unsuccessful due to electromagnetic interference. Patient was instructed to extend his arm above his head on the ipsilateral side of the ICD, thus increasing the distance between LVAD and ICD, eliminating the interaction to allow reprogramming of the device.