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Guo H, Li LH, Lv XH, Su FZ, Chen J, Xiao F, Shi M, Xie YB. Association Between Preoperative Sleep Disturbance and Postoperative Delirium in Elderly: A Retrospective Cohort Study. Nat Sci Sleep 2024; 16:389-400. [PMID: 38646462 PMCID: PMC11032121 DOI: 10.2147/nss.s452517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/04/2024] [Indexed: 04/23/2024] Open
Abstract
Purpose Postoperative sleep disturbance, characterized by diminished postoperative sleep quality, is a risk factor for postoperative delirium (POD); however, the association between pre-existing sleep disturbance and POD remains unclear. This study aimed to evaluate the association between preoperative sleep disturbance and POD in elderly patients after non-cardiac surgery. Patients and methods This retrospective cohort study was conducted at a single center and enrolled 489 elderly patients who underwent surgery between May 1, 2020, and March 31, 2021. Patients were divided into the sleep disorder (SD) and non-sleep disorder (NSD) groups according to the occurrence of one or more symptoms of insomnia within one month or sleep- Numerical Rating Scale (NRS)≥6 before surgery. The primary outcome was the incidence of POD. Propensity score matching analysis was performed between the two groups. Multiple logistic regression analysis was performed to identify the risk factors for POD. Results In both the unmatched cohort (16.0% vs 6.7%, P=0.003) and the matched cohort (17.0% vs 6.2%, P=0.023), the incidence of POD was higher in the SD group than in the NSD group. In addition, the postoperative sleep quality and the VAS score at postoperative 24 h were significantly lower in the SD group than in the NSD group. Multivariate logistic regression analysis indicated that age (Odds Ratio, 1.13 [95% CI: 1.04-1.23], P=0.003) and preoperative sleep disturbance (Odds Ratio, 3.03 [95% CI: 1.09-9.52], P=0.034) were independent risk factors for the development of POD. Conclusion The incidence of POD was higher in patients with pre-existing sleep disturbance than those without it. Whether improving sleep quality for preoperative sleep disturbance may help prevent POD remains to be determined.
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Affiliation(s)
- Hao Guo
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Li-Heng Li
- Department of Anesthesiology, The Guilin Municipal Hospital of Traditional Chinese Medicine, Guangxi, People’s Republic of China
| | - Xiao-Hong Lv
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Feng-Zhi Su
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Jie Chen
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Fei Xiao
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Min Shi
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yu-Bo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
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Wang X, Wu Y, Li X, Hong J, Zhang M. Log odds of negative lymph nodes/T stage ratio (LONT): A new prognostic tool for differentiated thyroid cancer without metastases in patients aged 55 and older. Front Endocrinol (Lausanne) 2023; 14:1132687. [PMID: 37033269 PMCID: PMC10073738 DOI: 10.3389/fendo.2023.1132687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND The optimal approach to assess the postoperative status of lymph nodes in differentiated thyroid cancer (DTC) remains controversial. Our aim was to determine if the log odds of negative lymph nodes/T stage ratio (LONT) could serve as a new prognostic and predictive tool for DTC without metastases in patients aged ≥ 55 years. METHODS The Surveillance, Epidemiology, and End Results (SEER) database was used to study the role of LONT in patients aged ≥55 years diagnosed with DTC without metastases. The primary outcome was overall survival (OS). The Kaplan-Meier method and the Cox proportional hazard regression model were used to calculate the outcome. Moreover, the robustness of research findings was evaluated using sensitivity analyses. RESULTS A total of 21,172 DTC patients aged ≥55 years without distant metastasis were enrolled. Multivariate Cox regression analyses and a "floating absolute risk" analysis showed that a LONT ≥0.920 (vs. -0.56 to 0.92) was a protective factor for OS in DTC patients. Sensitivity analyses revealed an E-value of 1.98 for the obtained LONT value. In subgroup analyses, LONT was correlated significantly with OS in different subgroups of negative lymph nodes, stage-I-II subgroups and the N0 subgroup. The conditional probability of survival of DTC improved with prolonged survival time in the LONT ≥0.920 group. CONCLUSION A high LONT was associated with longer OS compared with low LONT in patients aged ≥55 years with non-metastatic DTC. LONT could provide valuable information for undertaking postoperative evaluations.
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Affiliation(s)
- Xuezhen Wang
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yufan Wu
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiaoxia Li
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jinsheng Hong
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- *Correspondence: Jinsheng Hong, ; Mingwei Zhang,
| | - Mingwei Zhang
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- *Correspondence: Jinsheng Hong, ; Mingwei Zhang,
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Goldberg EM, Lin MP, Burke LG, Jiménez FN, Davoodi NM, Merchant RC. Perspectives on Telehealth for older adults during the COVID-19 pandemic using the quadruple aim: interviews with 48 physicians. BMC Geriatr 2022; 22:188. [PMID: 35260091 PMCID: PMC8903127 DOI: 10.1186/s12877-022-02860-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/18/2022] [Indexed: 12/01/2022] Open
Abstract
Background Telehealth delivery expanded quickly during the COVID-19 pandemic after the reduction of payment and regulatory barriers, but older adults are the least likely to benefit from this expansion. Little is known about physician experiences initiating telehealth and factors that fostered or discouraged adoption during the COVID-19 pandemic with older adult patients. Therefore, our objective was to understand experiences of frontline physicians caring for older adults via telehealth during the COVID-19 pandemic. Methods We conducted semi-structured interviews from September 2020 to November 2020 with 48 physicians. We recruited a diverse sample of geriatricians (n = 18), primary care (n = 15), and emergency (n = 15) physicians from all United Stated (US) regions, rural-urban settings, and academic-community practices who cared for older adult patients during the pandemic using purposive sampling methods. We completed framework analysis of the transcribed interviews to identify emerging themes and used the Quadruple Aim to organize themes. Results Frontline physicians described telehealth as a more flexible, value-based, and patient-centered mode of health care delivery. Benefits of using telehealth to treat older adults included reducing deferred care and increasing timely care, improving efficiency for physicians, enhancing communication with caregivers and patients, reducing patient travel burdens, and facilitating health outreach and education. Challenges included unequal access for rural, older, or cognitively impaired patients. Physicians noted that payment parity with in-person visits, between video and telephone visits, and relaxation of restrictive regulations would enhance their ability to continue to offer telehealth. Conclusions Frontline physicians who treated older adults during the COVID-19 pandemic were largely in favor of continuing telehealth use beyond the pandemic; however, they noted that sustainability would depend on enacting policies that address access inequities and reimbursement concerns. Our data provide policy insights that if placed into action could facilitate the long-term success of telehealth and encourage a more flexible healthcare delivery system in the US. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-02860-8.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 55 Claverick Street, Second floor, Providence, RI, 02903, USA. .,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Michelle P Lin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura G Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | - Roland C Merchant
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Bilazarian A, Hovsepian V, Kueakomoldej S, Poghosyan L. A Systematic Review of Primary Care and Payment Models on Emergency Department Use in Patients Classified as High Need, High Cost. J Emerg Nurs 2021; 47:761-777.e3. [PMID: 33744017 DOI: 10.1016/j.jen.2021.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/21/2021] [Accepted: 01/28/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Reducing costly and harmful ED use by patients classified as high need, high cost is a priority across health care systems. The purpose of this systematic review was to evaluate the impact of various primary care and payment models on ED use and overall costs in patients classified as high need, high cost. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search was performed from January 2000 to March 2020 in 3 databases. Two reviewers independently appraised articles for quality. Studies were eligible if they evaluated models implemented in the primary care setting and in patients classified as high need, high cost in the United States. Outcomes included all-cause and preventable ED use and overall health care costs. RESULTS In the 21 articles included, 4 models were evaluated: care coordination (n = 8), care management (n = 7), intensive primary care (n = 4), and alternative payment models (n = 2). Statistically significant reductions in all-cause ED use were reported in 10 studies through care coordination, alternative payment models, and intensive primary care. Significant reductions in overall costs were reported in 5 studies, and 1 reported a significant increase. Care management and care coordination models had mixed effects on ED use and overall costs. DISCUSSION Studies that significantly reduced ED use had shared features, including frequent follow-up, multidisciplinary team-based care, enhanced access, and care coordination. Identifying primary care models that effectively enhance access to care and improve ongoing chronic disease management is imperative to reduce costly and harmful ED use in patients classified as high need, high cost.
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Berenson R, Shartzer A. The Mismatch of Telehealth and Fee-for-Service Payment. JAMA HEALTH FORUM 2020; 1:e201183. [DOI: 10.1001/jamahealthforum.2020.1183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Adele Shartzer
- The Urban Institute Health Policy Center, Washington, DC
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Ravi B, Pincus D, Choi S, Jenkinson R, Wasserstein DN, Redelmeier DA. Association of Duration of Surgery With Postoperative Delirium Among Patients Receiving Hip Fracture Repair. JAMA Netw Open 2019; 2:e190111. [PMID: 30794305 PMCID: PMC6484601 DOI: 10.1001/jamanetworkopen.2019.0111] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Postoperative delirium in older adults receiving hip fracture surgery is associated with morbidity and increased health care costs, yet little is known of potential modifiable factors that may help limit the risks. OBJECTIVE To use population-wide individual-level data on the duration of hip fracture surgery to determine whether prolonged surgical times and type of anesthesia are associated with an increased risk of postoperative delirium. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study analyzed patients aged 65 years and older receiving hip fracture surgery between April 1, 2009, and March 30, 2017, at 80 hospitals in Ontario, Canada. Generalized estimated equations with logistic regression analysis were used to determine the relationship between procedure duration, type of anesthesia, and the occurrence of postoperative delirium. Restricted cubic splines were also generated to visualize this relationship. Data analysis was conducted from July to October 2018, revision in January 2019. EXPOSURE Surgery duration, measured as the total time in the operating room. MAIN OUTCOMES AND MEASURES A diagnosis of postoperative delirium during hospitalization. RESULTS Among 68 131 patients with surgically managed hip fracture (median [interquartile range] age, 84 [78-89] years; 72% women) identified, 7150 patients experienced postoperative delirium. In total, 26 853 patients (39.4%) received general anesthesia. Receiving general anesthesia was associated with a slightly higher rate of postoperative delirium compared with not receiving general anesthesia (2943 [11.0%] vs 4207 [10.2%]; P = .001). The risk for delirium increased with increased surgical duration-every 30-minute increase in the duration of surgery was associated with a 6% increase in the risk for delirium (adjusted odds ratio, 1.06; 95% CI, 1.03-1.08; P < .001). Prolonged surgical duration was associated with a higher incidence of postoperative delirium, and the risk was higher was in patients who had received general anesthesia (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; P < .001) than in those patients who did not receive GA (adjusted odds ratio, 1.04; 95% CI, 1.01-1.08; P = .01). CONCLUSIONS AND RELEVANCE Among older adults receiving hip fracture surgery, both an increased duration of surgery and receiving a general anesthetic were associated with an increased risk for postoperative delirium.
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Affiliation(s)
- Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Daniel Pincus
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Stephen Choi
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Richard Jenkinson
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David N. Wasserstein
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Donald A. Redelmeier
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Carlo AD, Unützer J, Ratzliff ADH, Cerimele JM. Financing for Collaborative Care - A Narrative Review. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2018; 5:334-344. [PMID: 30083495 PMCID: PMC6075691 DOI: 10.1007/s40501-018-0150-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW Collaborative care (CoCM) is an evidence-based model for the treatment of common mental health conditions in the primary care setting. Its workflow encourages systematic communication among clinicians outside of face-to-face patient encounters, which has posed financial challenges in traditional fee-for-service reimbursement environments. RECENT FINDINGS Organizations have employed various financing strategies to promote CoCM sustainability, including external grants, alternate payment model contracts with specific payers and the use of billing codes for individual components of CoCM. In recent years, Medicare approved fee-for-service, time-based billing codes for CoCM that allow for the reimbursement of patient care performed outside of face-to-face encounters. A growing number of Medicaid and commercial payers have followed suit, either recognizing the fee-for-service codes or contracting to reimburse in alternate payment models. SUMMARY Although significant challenges remain, novel methods for payment and cooperative efforts among insurers have helped move CoCM closer to financial sustainability.
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Affiliation(s)
- Andrew D Carlo
- University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences - 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560
| | - Jürgen Unützer
- University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences - 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560
| | - Anna D H Ratzliff
- University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences - 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560
| | - Joseph M Cerimele
- University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences - 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560
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Rocque GB, Williams CP, Jones MI, Kenzik KM, Williams GR, Azuero A, Jackson BE, Halilova KI, Meneses K, Taylor RA, Partridge E, Pisu M, Kvale EA. Healthcare utilization, Medicare spending, and sources of patient distress identified during implementation of a lay navigation program for older patients with breast cancer. Breast Cancer Res Treat 2017; 167:215-223. [DOI: 10.1007/s10549-017-4498-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/01/2017] [Indexed: 01/06/2023]
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Abstract
Improving care transitions, or "handoffs" as patients migrate from one care setting to another, is a priority across stakeholder groups and health-care settings and additionally is included in national health-care goals set forth in the National Quality Strategy. Although many demonstrations of improved care transitions have succeeded, particularly for hospital discharges, ensuring consistent, high-quality, and safe transitions of care remains challenging. This paper highlights the potential for health information technology to become an increasing part of effective transitional care interventions, with the potential to reduce the resource burden currently associated with effective care transitions, the ability to spread improved practices to larger numbers of patients and providers efficiently and at scale, and, as health technology interoperability increases, the potential to facilitate critical information flow and feedback loops to clinicians, patients, and caregivers across disparate information systems and care settings.
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Ryan M, Merrick EL, Hodgkin D, Horgan CM, Garnick DW, Panas L, Ritter G, Blow FC, Saitz R. Drinking patterns of older adults with chronic medical conditions. J Gen Intern Med 2013; 28:1326-32. [PMID: 23609178 PMCID: PMC3785666 DOI: 10.1007/s11606-013-2409-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 01/10/2013] [Accepted: 02/27/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Understanding alcohol consumption patterns of older adults with chronic illness is important given the aging baby boomer generation, the increase in prevalence of chronic conditions and associated medication use, and the potential consequences of excessive drinking in this population. OBJECTIVES To estimate the prevalence of alcohol consumption patterns, including at-risk drinking, in older adults with at least one of seven common chronic conditions. DESIGN/METHODS This descriptive study used the nationally representative 2005 Medicare Current Beneficiary Survey linked with Medicare claims. The sample included community-dwelling, fee-for-service beneficiaries 65 years and older with one or more of seven chronic conditions (Alzheimer's disease and other senile dementia, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hypertension, and stroke; n = 7,422). Based on self-reported alcohol consumption, individuals were categorized as nondrinkers, within-guidelines drinkers, or at-risk drinkers (exceeds guidelines). RESULTS Overall, 30.9 % (CI 28.0-34.1 %) of older adults with at least one of seven chronic conditions reported alcohol consumption in a typical month in the past year, and 6.9 % (CI 6.0-7.8 %) reported at-risk drinking. Older adults with higher chronic disease burdens were less likely to report alcohol consumption and at-risk drinking. CONCLUSIONS Nearly one-third of older adults with selected chronic illnesses report drinking alcohol and almost 7 % drink in excess of National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines. It is important for physicians and patients to discuss alcohol consumption as a component of chronic illness management. In cases of at-risk drinking, providers have an opportunity to provide brief intervention or to offer referrals if needed.
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Affiliation(s)
- Marian Ryan
- Heller School for Social Policy and Management, Brandeis University, 415 South Street, MS035, Waltham, MA, 02454-9110, USA,
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Abstract
Despite widespread interest in the medical home model, there has been a lack of careful assessment of alternative methods to pay practices that serve as medical homes. This paper examines four specific payment approaches: enhanced fee-for-service payments for evaluation and management; additional codes for medical home activities within fee-for-service payments; per patient per month medical home payments to augment fee-for-service visit payments; and risk-adjusted, comprehensive per patient per month payments. Payment policies selected will affect both the adoption of the model and its longer-term evaluation. Evaluations of ongoing demonstrations should focus on payment design as well as on care--and cost.
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Affiliation(s)
- Katie Merrell
- Center for Health Research and Policy, Social and Scientific Systems Inc., Silver Spring, MD, USA.
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Allen KR, Hazelett SE, Radwany S, Ertle D, Fosnight SM, Moore PS. The Promoting Effective Advance Care for Elders (PEACE) Randomized Pilot Study: Theoretical Framework and Study Design. Popul Health Manag 2012; 15:71-7. [DOI: 10.1089/pop.2011.0004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kyle R. Allen
- Summa Health System, Akron, Ohio
- Northeastern Ohio Universities Colleges of Medicine and Pharmacy, Rootstown, Ohio
| | | | - Steven Radwany
- Summa Health System, Akron, Ohio
- Northeastern Ohio Universities Colleges of Medicine and Pharmacy, Rootstown, Ohio
| | - Denise Ertle
- The Area Agency on Aging 10B, Inc., Uniontown, Ohio
| | - Susan M. Fosnight
- Summa Health System, Akron, Ohio
- Northeastern Ohio Universities Colleges of Medicine and Pharmacy, Rootstown, Ohio
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Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood) 2011; 30:746-54. [PMID: 21471497 DOI: 10.1377/hlthaff.2011.0041] [Citation(s) in RCA: 467] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.
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Affiliation(s)
- Mary D Naylor
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Bao Y, Casalino LP, Ettner SL, Bruce ML, Solberg LI, Unützer J. Designing payment for Collaborative Care for Depression in primary care. Health Serv Res 2011; 46:1436-51. [PMID: 21609327 DOI: 10.1111/j.1475-6773.2011.01272.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To design a bundled case rate for Collaborative Care for Depression (CCD) that aligns incentives with evidence-based depression care in primary care. DATA SOURCES A clinical information system used by all care managers in a randomized controlled trial of CCD for older primary care patients. STUDY DESIGN We conducted an empirical investigation of factors accounting for variation in CCD resource use over time and across patients. CCD resource use at the patient-episode and patient-month levels was measured by number of care manager contacts and direct patient contact time and analyzed with count data (Poisson or negative binomial) models. PRINCIPAL FINDINGS Episode-level resource use varies substantially with patient's time in the program. Monthly use declines sharply in the first 6 months regardless of treatment response or remission status, but it remains stable afterwards. An adjusted episode or monthly case rate design better matches payment with variation in resource use compared with a fixed design. CONCLUSIONS Our findings lend support to an episode payment adjusted by number of months receiving CCD and a monthly payment adjusted by the ordinal month. Nonpayment tools including program certification and performance evaluation and reward systems are needed to fully align incentives.
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Affiliation(s)
- Yuhua Bao
- Department of Public Health, Weill Cornell Medical College, 402 E 67th St., New York, NY 10065, USA.
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Allen KR, Hazelett SE, Jarjoura D, Wright K, Fosnight SM, Kropp DJ, Hua K, Pfister EW. The after discharge care management of low income frail elderly (AD-LIFE) randomized trial: theoretical framework and study design. Popul Health Manag 2011; 14:137-42. [PMID: 21323461 DOI: 10.1089/pop.2010.0016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Interdisciplinary care management is advocated for optimal care of patients with many types of chronic illnesses; however, few models exist that have been tested using randomized trials. The purpose of this report is to describe the theoretical basis for the After Discharge Management of Low Income Frail Elderly (AD-LIFE) trial, which is an ongoing 2-group randomized trial (total n = 530) to test a chronic illness management and transitional care intervention. The intervention is based on Wagner's chronic illness care model and involves comprehensive posthospitalization nurse-led interdisciplinary care management for low income frail elders with chronic illnesses, employs evidence-based protocols that were developed using the Assessing Care of Vulnerable Elders (ACOVE) guidelines, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. The primary aim of the AD-LIFE trial is to test a chronic illness management intervention in vulnerable patients who are eligible for Medicare and Medicaid. This model, with its standardized, evidence-based medical and psychosocial intervention protocols, will be easily transportable to other sites interested in optimizing outcomes for chronically ill older adults. If the results of the AD-LIFE trial demonstrate the superiority of the intervention, then this data will be important for health care policy makers.
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Escoto KH, Ozminkowski RJ, Hawkins K, Hommer C, Barnowski C, Migliori R, Unützer J, Yeh C. Integrated Disease and Depression Management for Insureds in Medicare Supplement Plans. Psychiatr Ann 2010. [DOI: 10.3928/00485713-20100804-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
The purpose of this paper is to address why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home, and the relevance of such payment reforms as pay-for-performance and episodes/bundling. The review illustrates why prevalent physician payment mechanisms in the US have failed to adequately support primary care and why innovative approaches to primary care payment play such a prominent role in the PCMH discussion. FFS payment for office visits has never effectively rewarded all the activities that comprise prototypical primary care and may contribute to the "hamster on a treadmill" problems in current medical practice. Capitation payments are associated with risk adjustment challenges and, perhaps, public perceptions of conflict with patients' best interests. Most payers don't employ and therefore cannot generally place physicians on salary; while in theory such salary payments might neutralize incentives, operationally, "time is money;" extra effort devoted to meeting the needs of a more complex patient will likely reduce the services available to others. Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well. Yet, the conceptual alternative payment approaches, modified fee-for-service (including fee bundles), capitation, and salary, each have their own problems. Accordingly, new payment models will likely be required to support restoration of primary care to its proper role in the US health care system, and to promote and sustain the development of patient-centered medical homes.
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Affiliation(s)
| | - Eugene C. Rich
- Creighton University, Omaha, NE USA
- Mathematica Policy Research, Washington, DC USA
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Magnezi R, Elzam L, Kliker Y, Kedem R, Fire G, Wilf-Miron R. Cost awareness when prescribing treatment. ACTA ACUST UNITED AC 2010. [DOI: 10.12968/bjhc.2010.16.2.46416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Racheli Magnezi
- Department of Health System Management, School of Health Sciences, Ariel University Center, Israel
| | - Lilach Elzam
- Department of Health System Management, Faculty of Health Science, Ben Gurion University of the Negev, Israel
| | - Yaniv Kliker
- Department of Health System Management, Faculty of Health Science, Ben Gurion University of the Negev
| | - Ron Kedem
- The Faculty of Pedagogy, Constantine the Philosopher University, Slovakia
| | - Gil Fire
- Sourasky Medical Center, Department of Health System Management, School of Health Sciences, Ariel University Center
| | - Rachel Wilf-Miron
- MD, MHP, Quality Management, Maccabi Healthcare Services, Quality Management, Maccabi Healthcare Services, Israel
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Market failure, policy failure and other distortions in chronic disease markets. BMC Health Serv Res 2009; 9:102. [PMID: 19534822 PMCID: PMC2704185 DOI: 10.1186/1472-6963-9-102] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Accepted: 06/18/2009] [Indexed: 11/21/2022] Open
Abstract
Background The increasing prevalence of chronic disease represents a significant burden on most health systems. This paper explores the market failures and policy failures that exist in the management of chronic diseases. Discussion There are many sources of market failure in health care that undermine the efficiency of chronic disease management. These include incomplete information as well as information asymmetry between providers and consumers, the effect of externalities on consumer behaviour, and the divergence between social and private time preference rates. This has seen government and policy interventions to address both market failures and distributional issues resulting from the inability of private markets to reach an efficient and equitable distribution of resources. However, these have introduced a series of policy failures such as distorted re-imbursement arrangements across modalities and delivery settings. Summary The paper concludes that market failure resulting from a preference of individuals for 'immediate gratification' in the form of health care and disease management, rather than preventative services, where the benefits are delayed, has a major impact on achieving an efficient allocation of resources in markets for the management of chronic diseases. This distortion is compounded by government health policy that tends to favour medical and pharmaceutical interventions further contributing to distortions in the allocation of resources and inefficiencies in the management of chronic disease.
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Friedman B, Jiang HJ, Elixhauser A. Costly hospital readmissions and complex chronic illness. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2009; 45:408-21. [PMID: 19209836 DOI: 10.5034/inquiryjrnl_45.04.408] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
People with multiple chronic conditions account for a large and disproportionate share of total health care costs. One aspect of the high cost for such patients is a relatively high number of hospital admissions per year. This study aims to clarify how the rate of hospital readmissions and hospital cost per person in a year depend on a patient's number of different chronic conditions ("complexity"), severity of illness, principal diagnosis at discharge, payer group, and other variables. We use a database of all hospital discharges for adults in six states. The number of different chronic conditions has a smoothly increasing effect on readmissions and cost per year, and there are notable differences by payer group. We offer illustrations of the potential savings from reducing total inpatient cost and readmissions in narrowly targeted populations with the most complex problems. The study's methods and descriptive data potentially could be useful for health plans and their sponsors (employers, government) when they design strategies to address the high cost of complex chronic illness.
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Affiliation(s)
- Bernard Friedman
- Center for Delivery, Organization and Markets, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, USA.
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Pham HH, O'Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians' links to other physicians through Medicare patients: the scope of care coordination. Ann Intern Med 2009; 150:236-42. [PMID: 19221375 PMCID: PMC3718023 DOI: 10.7326/0003-4819-150-4-200902170-00004] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primary care physicians are expected to coordinate care for their patients. OBJECTIVE To assess the number of physician peers providing care to the Medicare patients of a primary care physician. DESIGN Cross-sectional analysis of claims data. SETTING Fee-for-service Medicare in 2005. PARTICIPANTS 2284 primary care physicians who responded to the 2004 to 2005 Community Tracking Study Physician Survey. MEASUREMENTS Primary patients for each physician were defined as beneficiaries for whom the physician billed for more evaluation and management visits than any other physician in 2005. The number of physician peers for each physician was the sum of other unique physicians that the index physician's primary patients visited plus other unique physicians who served as the primary physician for each of the index physician's nonprimary patients during 2005. RESULTS The typical primary care physician has 229 (interquartile range, 125 to 340) other physicians working in 117 (interquartile range, 66 to 175) practices with which care must be coordinated, equivalent to an additional 99 physicians and 53 practices for every 100 Medicare beneficiaries managed by the primary care physician. When only the 31% of a primary care physician's primary patients who had 4 or more chronic conditions was considered, the median number of peers involved was still substantial (86 physicians in 36 practices). The number of peers varied with geographic region, practice type, and reliance on Medicaid revenues. LIMITATIONS Estimates are based only on fee-for-service Medicare patients and physician peers, and the number of peers is therefore probably an underestimate. The modest response rate of the Community Tracking Study Physician Survey may bias results in unpredictable directions. CONCLUSION In caring for his or her own primary and nonprimary patients during a single year, each primary care physician potentially must coordinate with a large number of individual physician colleagues who also provide care to these patients. FUNDING National Institute on Aging, American Medical Group Association, and the Robert Wood Johnson Foundation.
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Affiliation(s)
- Hoangmai H Pham
- Center for Studying Health System Change, Washington, DC 20024, USA.
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Affiliation(s)
- Jane G. Zapka
- Department of Biostatistics, Bioinformatics and Epidemiology, Medical University of South Carolina, Charleston, South Carolina,
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Preoperative β-blocker use: impact of national guidelines on clinical practice. J Clin Anesth 2008; 20:122-8. [DOI: 10.1016/j.jclinane.2007.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Accepted: 09/21/2007] [Indexed: 11/21/2022]
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Wenger NS, Roth CP, Shekelle P. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set. J Am Geriatr Soc 2007; 55 Suppl 2:S247-52. [PMID: 17910544 DOI: 10.1111/j.1532-5415.2007.01328.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To update and increase the comprehensiveness of the Assessing Care of Vulnerable Elders (ACOVE) set of process-of-care quality indicators (QIs) for the medical care provided to vulnerable elders and to keep up with the constantly changing medical literature, the QIs were revised and expanded. DESIGN The ACOVE Clinical Committee expanded the number of measured conditions to 26 in the revised (ACOVE-3) set. For each condition, a content expert created potential QIs and, based on systematic reviews, developed a peer-reviewed monograph detailing each QI and its supporting evidence. Using these literature reviews, multidisciplinary panels of clinical experts participated in two rounds of anonymous ratings and a face-to-face group discussion to evaluate whether the QIs were valid measures of quality of care using a process that is an explicit combination of scientific evidence and professional consensus. The Clinical Committee evaluated the coherence of the complete set of QIs that the expert panels rated as valid. RESULTS ACOVE-3 contains 392 QIs covering 14 different types of care processes (e.g., taking a medical history, performing a physical examination) and all four domains of care: screening and prevention (31% of QIs), diagnosis (20%), treatment (35%), and follow-up and continuity (14%). All QIs also apply to community-dwelling patients aged 75 and older. CONCLUSION ACOVE-3 contains a set of QIs to comprehensively measure the care provided to vulnerable older persons at the level of the health system, health plan, or medical group. These QIs can be applied to identify areas of care in need of improvement and can form the basis of interventions to improve care.
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Affiliation(s)
- Neil S Wenger
- RAND Health, Santa Monica, California, and Division of General Internal Medicine and Health Services Research, University of California at Los Angeles, Los Angeles, CA 90407, USA.
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Bayliss EA, Bosworth HB, Noel PH, Wolff JL, Damush TM, Mciver L. Supporting self-management for patients with complex medical needs: recommendations of a working group. Chronic Illn 2007; 3:167-75. [PMID: 18083671 DOI: 10.1177/1742395307081501] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Increasing numbers of persons live with complex chronic medical needs and are at risk for poor health outcomes. These patients require unique self-management support, as they must manage many, often interacting, tasks. As part of a conference on Managing Complexity in Chronic Care sponsored by the Department of Veterans Affairs, a working group was convened to consider self-management issues specific to complex chronic care. In this paper, we assess gaps in current knowledge on self-management support relevant to this population, report on the recommendations of our working group, and discuss directions for future study. We conclude that this population requires specialized, multidimensional self-management support to achieve a range of patient-centred goals. New technologies and models of care delivery may provide opportunities to develop this support. Validation and quantification of these processes will require the development of performance measures that reflect the needs of this population, and research to prove effectiveness.
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Affiliation(s)
- E A Bayliss
- Clinical Research Unit, Kaiser Permanente, PO Box 378066, Denver, CO 80237-8066, USA.
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Goroll AH, Berenson RA, Schoenbaum SC, Gardner LB. Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. J Gen Intern Med 2007; 22:410-5. [PMID: 17356977 PMCID: PMC1824766 DOI: 10.1007/s11606-006-0083-2] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed.
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Affiliation(s)
- Allan H. Goroll
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114 USA
| | | | | | - Laurence B. Gardner
- Department of Medicine, University of Miami School of Medicine, Miami, FL USA
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Bachman J, Pincus HA, Houtsinger JK, Unützer J. Funding mechanisms for depression care management: opportunities and challenges. Gen Hosp Psychiatry 2006; 28:278-88. [PMID: 16814626 DOI: 10.1016/j.genhosppsych.2006.03.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Revised: 03/03/2006] [Accepted: 03/06/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Inconsistent third-party reimbursement for depression care management is a significant economic barrier to the utilization and sustainability of the chronic illness care model in primary care practice settings. We review common mechanisms used to procure payment for depression care management services, discuss obstacles encountered and suggest future directions. METHOD We describe several extant models for funding depression care management services in use at the demonstration sites of the Robert Wood Johnson Foundation funded "Depression in Primary Care" project and similar programs. We derived this information from ongoing discussions with the sites' project directors and through an extensive electronic literature search on "care management, funding mechanisms and depression." RESULTS Funding mechanisms include (a) practice-based care management on a fee-for-service basis, (b) practice-based care management under contract to health plans, (c) global capitation, (d) flexible infrastructure support for chronic care management, (e) health-plan-based care management, (f) third-party-based care management under contract to health plans and (g) hybrid models. CONCLUSIONS While substantial obstacles remain in the way of fully implementing these depression care management funding mechanisms (e.g., variations in care managers' credentials and work locations and third-party payer concerns about overutilization and transaction costs), several recent policy advances provide some optimism for the potential adoption of financial mechanisms to support and disseminate these evidence-based practices.
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Affiliation(s)
- John Bachman
- Depression in Primary Care: Linking Clinical and Systems Strategies, National Program Office, Pittsburgh, PA 15213, USA.
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Hendrix CC, Wojciechowski CW. Chronic Care Management for the Elderly: An Opportunity for Gerontological Nurse Practitioners. ACTA ACUST UNITED AC 2005; 17:263-7. [PMID: 15982246 DOI: 10.1111/j.1745-7599.2005.0044.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To discuss the role that gerontological nurse practitioners (GNPs) may play in providing chronic care management for the elderly. DATA SOURCES Review of recent literature on chronic care management, personal experience of the authors in caring for older adults under the chronic care management model, and a case study. CONCLUSIONS GNPs are the most appropriate practitioners to provide and coordinate chronic care management to the population that needs it most--the elderly. IMPLICATIONS FOR PRACTICE Demographic shifts in the United States have increased the number of people with chronic illnesses; however, the nation's healthcare delivery system has not significantly evolved to meet the changing needs of its population. As a result, many people, especially older adults, suffer needlessly, and healthcare costs continue to rise. Chronic care management may alleviate older adults' chronic health problems, reduce expenditures for their health care, and promote their satisfaction and quality of life.
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Stock RD, Reece D, Cesario L. Developing a Comprehensive Interdisciplinary Senior Healthcare Practice. J Am Geriatr Soc 2004; 52:2128-33. [DOI: 10.1111/j.1532-5415.2004.52576.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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