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A BSTRACTS
physician resistance to accepting prescribing recommendations, including
gradual dose reductions.
Conclusions: The responses of the NH leaders, staff and consultant
pharmacists suggest widespread knowledge gaps regarding antipsychotic
benefits and risks, and suggest a need for increase evidence
dissemination and broad organizational change.
C107
A Discrete Choice Analysis of Older Adults’ Preferences for
Colorectal Cancer Screening Tests.
C. E. Kistler, 1 T. Hess, 2 M. Pignone, 1 S. Hawley, 3 C. Lewis. 1 1.
University of North Carolina at Chapel Hill, Chapel Hill, NC; 2.
North Carolina State University, Raleigh, NC; 3. University of
Michigan, Ann Arbor, MI.
Supported By: This study was supported by the Agency for
Healthcare Research and Quality K12 HS19468-01 (Kistler) and institutional
support from the University of North Carolina at Chapel
Hill and North Carolina State University.
Background: Tailoring colorectal cancer (CRC) screening tests
to older adults’ preferences may improve adherence to CRC screening.
Given the heterogeneity of health status among older adults, different
attributes other than mortality reduction may be key factors
when deciding upon a preferred CRC screening test. This study aims
to describe older adults’ preferences for colorectal cancer screening
test attributes via a discrete choice analysis.
Methods: We conducted a discrete choice analysis among adults
aged 70 and older who volunteered at either a local Family Medicine
clinic or a local research site. Participants were first asked to rank
four key attributes in order of importance: mortality reduction, risk of
complications, test frequency, and testing procedure. Next, in 10 different
scenarios, they were asked to choose between two hypothetical
CRC screening tests. Each hypothetical test contained varying levels
of the four key attributes. Responses were used to calculate the overall
importance of these attributes. These results were then compared
to the initial ranking exercise.
Results: Preliminary results include 63 participants with a mean
age of 76 years (range 70-90) of whom 51 were White, 11 African
American, and 1 American Indian. All but 3 participants had been
screened at least once for colorectal cancer. Initially, 44% of participants
(28/63) ranked mortality reduction as the most important test
attribute; 44% (28/63) ranked risk of complications second; 40%
(25/63)ranked test frequency third; and 48% (30/63) ranked testing
procedures as the least important attribute. A discrete choice analysis
determined the attribute importance from most to least was: testing
procedure (28%), test frequency (27%), risk of complications (23%),
and mortality reduction (23%).
Conclusion: Older adults appear to have differing preferences
for CRC screening test attributes depending on how the information
is presented. A discrete choice analysis appears to shift older adults’
preference away from prioritizing mortality reduction and towards
other test attributes.
C108
Qualitative Approach to Understanding Medication Challenges
among Older Adults after Hospital Discharge.
D. Liu, 1,2 S. Rennke, 1 H. Chi, 1 M. Steinman. 1,2 1. Internal Medicine,
UCSF, San Francisco, CA; 2. Geriatrics, SF VA Medical Center, San
Francisco, CA.
Supported By: Supported in part by NIH grant 1K23-AG030999
(PI: Steinman, M)
Background: Patients age 65 years and older have a 19% risk of
30 day readmission after hospital discharge, and medication safety
plays an important role in reducing this risk. We piloted a telephonebased
qualitative study to better understand the needs older adults
have with medications after recent hospital discharge.
Methods:The study population included patients 2-4 weeks after
discharge from the general medicine service at an academic teaching
hospital. Inclusion criteria were age ≥65 years, English-speaking, and
discharged home with ≥ 5 medications. We used semi-structured,
open-ended questions assessing problems with medication since discharge,
resources patients have, and what additional help they need.
Transcriptions were analyzed from a grounded theory approach.
For participants who answered “no problems,” we used common scenarios
based on the medical literature as prompts. Concurrent with
our study, hospital discharge nurses attempted to reach all participants
with a standard post-discharge telephone call that included 2
medication questions (Did you fill your prescriptions? Did you understand
your medication instructions?).
Results: We have conducted 9 interviews. All interviewees endorsed
some medication-related problem including adherence, titration,
side effects, and financial difficulty. Three initially denied any
problems, but in response to prompts did endorse at least one. Six of
the participants received the standard post-discharge phone call, but
none of these revealed any medication problems. Participants identified
needs at discharge along themes of lack of communication (“I
don’t think anyone has any time to discuss with me before I left”) and
inclusion of family in discharge planning. Four participants denied
needing any additional help at discharge with reasons being family
support or confidence in self ability. The latter group, however, qualified
their response by saying they did “not yet” need assistance.
Conclusion: Our study suggests that the brief post-discharge
phone call after discharge fails to identify common medication problems
among older patients. The themes of family and communication
suggest focal points for future study and design of discharge programs.
Even participants who denied needing assistance still qualified
their response with a “yet,” suggesting needs are a moving target.
C109
Effects of a randomized controlled trial comparing reimbursement
of care coordination to pay-for-performance in primary care.
D. A. Dorr, 1 G. S. Olsen, 1 M. Pierre-Jacques Williams, 1
C. P. Brunker. 2,3 1. Medical Informatics & Clinical Epidemiology,
OHSU, Portland, OR; 2. Geriatrics, Intermountain Healthcare, Salt
Lake City, UT; 3. Geriatrics, University of Utah, Salt Lake City, UT.
Supported By: The John A. Hartford Foundation, AHRQ
Background:Addressing patients’ longitudinal coordination needs
may reduce hospitalizations and improve quality while lowering costs,
particularly for older adults with multiple chronic illnesses. Yet, most
payment structures are fee-for-service or quality measure-based rather
than coordination-based. We tested the hypothesis that incentives for
care coordination would increase coordination activities and reduce utilization
more than traditional quality measure-based pay-for-performance
in a cluster randomized controlled trial of 6 primary care clinics.
Methods: Clinics were randomized into two arms: 3 received payment
for improvement on a self-selected set of 5 validated quality measures
(quality) and 3 received payment for assessment, education, goal
setting, motivational interviewing, and communication activities (coordination).
All clinics had designated, trained care managers and health
IT that provided interactive quality reports, tracked and reminded
about services, and facilitated risk-based population management. Patients
were eligible if seen twice during the 3 year study period. Patients
were analyzed in two groups: 1) preselected based on risk of hospitalization
and death; 2) enrolled by the care manager. Descriptive statistics
were computed to compare quality and care coordination encounters.
Results: 27,001 patients were eligible for the study; 18% were
preselected as high risk; 15% were enrolled in care management. In
all, 20% of patients were >65; however, they were 50% of high risk
and 36% of referred patients. Coordination clinics performed 1.8
times the coordination activities, including 4.3 times the education,
3.1 times the communication, and 3.9 times the motivational interviewing
as quality clinics. Quality clinics increased their absolute performance
on selected quality measures by 10.8% vs 5.1%.
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AGS 2012 ANNUAL MEETING