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OBJECTIVES: To evaluate the effect of intensive systolic blood pressure (SBP) control in older adults with hypertension, considering cognitive and physical function. DESIGN: Secondary analysis. SETTING: Systolic Blood Pressure Intervention Trial (SPRINT) PARTICIPANTS: Adults 80 years or older. INTERVENTION: Participants with hypertension but without diabetes (N = 1167) were randomized to an SBP target below 120 mm Hg (intensive treatment) vs a target below 140 mm Hg (standard treatment). MEASUREMENTS: We measured the incidence of cardiovascular disease (CVD), mortality, changes in renal function, mild cognitive impairment (MCI), probable dementia, and serious adverse events. Gait speed was assessed via a 4‐m walk test, and the Montreal Cognitive Assessment (MoCA) was used to quantify baseline cognitive function. RESULTS: Intensive treatment led to significant reductions in cardiovascular events (hazard ratio [HR] =.66; 95% confidence interval [CI] =.49‐.90), mortality (HR =.67; 95% CI =.48‐.93), and MCI (HR =.70; 95% CI =.51‐.96). There was a significant interaction (P <.001) whereby participants with higher baseline scores on the MoCA derived strong benefit from intensive treatment for a composite of CVD and mortality (HR =.40; 95% CI =.28‐.57), with no appreciable benefit in participants with lower scores on the MoCA (HR = 1.33 = 95% CI =.87‐2.03). There was no evidence of heterogeneity of treatment effects with respect to gait speed. Rates of acute kidney injury and declines of at least 30% in estimated glomerular filtration rate were increased in the intensive treatment group with no between‐group differences in the rate of injurious falls. CONCLUSION: In adults aged 80 years or older, intensive SBP control lowers the risk of major cardiovascular events, MCI, and death, with increased risk of changes to kidney function. The cardiovascular and mortality benefits of intensive SBP control may not extend to older adults with lower baseline cognitive function. Trial Registration: Clinicaltrials.gov identifier: NCT01206062. J Am Geriatr Soc 68:496–504, 2020 [ABSTRACT FROM AUTHOR]

OBJECTIVES: Concern about falling is common among older hypertension patients and could impact decisions to intensify blood pressure therapy. Our aim was to determine whether intensive therapy targeting a systolic blood pressure (SBP) of 120 mm Hg is associated with greater changes in concern about falling when compared with standard therapy targeting an SBP of 140 mm Hg. DESIGN: Subsample analysis of participants randomized to either intensive or standard therapy in the Systolic Blood Pressure Intervention Trial (SPRINT). SETTING: Approximately 100 outpatient sites. PARTICIPANTS: A total of 2313 enrollees in SPRINT; participants were all age 50 or older (mean = 69 y) and diagnosed with hypertension. MEASUREMENTS: Concern about falling was described by the shortened version of the Falls Efficacy Scale International as measured at baseline, 6 months, 1 year, and annually thereafter. RESULTS: Concern about falling showed a small but significant increase over time among all hypertension patients. No differences were noted, however, among those randomized to intensive vs standard therapy (P =.95). Among participants younger than 75 years, no increase in concern about falling over time was noted, but among participants aged 75 years and older, the mean falls self‐efficacy score increased by.3 points per year (P <.0001). No differences were observed between the intensive and standard treatment groups when stratified by age (P =.55). CONCLUSION: Intensive blood pressure therapy is not associated with increased concern about falling among older hypertension patients healthy enough to participate in SPRINT. J Am Geriatr Soc 68:614–618, 2020 [ABSTRACT FROM AUTHOR]

Background: The previously published results of the Systolic Blood Pressure Intervention Trial showed that among participants with hypertension and an increased cardiovascular risk, but without diabetes, the rates of cardiovascular events were lower among those who were assigned to a target systolic blood pressure of less than 120 mm Hg (intensive treatment) than among those who were assigned to a target of less than 140 mm Hg (standard treatment). Whether such intensive treatment affected patient-reported outcomes was uncertain; those results from the trial are reported here.Methods: We randomly assigned 9361 participants with hypertension to a systolic blood-pressure target of less than 120 mm Hg or a target of less than 140 mm Hg. Patient-reported outcome measures included the scores on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Veterans RAND 12-Item Health Survey, the Patient Health Questionnaire 9-item depression scale (PHQ-9), patient-reported satisfaction with their blood-pressure care and blood-pressure medications, and adherence to blood-pressure medications. We compared the scores in the intensive-treatment group with those in the standard-treatment group among all participants and among participants stratified according to physical and cognitive function.Results: Participants who received intensive treatment received an average of one additional antihypertensive medication, and the systolic blood pressure was 14.8 mm Hg (95% confidence interval, 14.3 to 15.4) lower in the group that received intensive treatment than in the group that received standard treatment. Mean PCS, MCS, and PHQ-9 scores were relatively stable over a median of 3 years of follow-up, with no significant differences between the two treatment groups. No significant differences between the treatment groups were noted when participants were stratified according to baseline measures of physical or cognitive function. Satisfaction with blood-pressure care was high in both treatment groups, and we found no significant difference in adherence to blood-pressure medications.Conclusions: Patient-reported outcomes among participants who received intensive treatment, which targeted a systolic blood pressure of less than 120 mm Hg, were similar to those among participants who received standard treatment, including among participants with decreased physical or cognitive function. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062 .). [ABSTRACT FROM AUTHOR]

Objectives To determine the extent of concern about falling in older adults with hypertension, whether lower blood pressure ( BP) and greater use of antihypertensive medications are associated with greater concern about falling, and whether lower BP has a greater effect on concern about falling in older and more functionally impaired individuals. Design Secondary analysis involving cross-sectional study of baseline characteristics of participants enrolled in the Systolic Blood Pressure Intervention Trial ( SPRINT). Setting Approximately 100 outpatient sites. Participants SPRINT enrollees aged 50 and older (mean age 69) diagnosed with hypertension (N = 2,299). Measurements Concern about falling was determined using the shortened version of the Falls Efficacy Scale International as measured at the baseline examination. Results Mild concern about falling was present in 29.3% of participants and moderate to severe concern in 17.9%. Neither low BP (systolic BP<120 mmHg, diastolic BP <70 mmHg) nor orthostatic hypotension was associated with concern about falling ( P > .10). Participants with moderate to severe concern about falling were taking significantly more antihypertensive medications than those with mild or no concern. After adjusting for baseline characteristics, no associations were evident between BP, medications, and concern about falling. Results were similar in older and younger participants; interactions between BP and age and functional status were not significantly associated with concern about falling. Conclusion Although concern about falling is common in older adults with hypertension, it was not found to be associated with low BP or use of more antihypertensive medications in baseline data from SPRINT. [ABSTRACT FROM AUTHOR]

Background: Patients with mental health conditions (MHCs) experience poor anticoagulation control when using warfarin, but we have limited knowledge of the association between specific mental illness and warfarin treatment outcomes. Objective: To examine the relationship between the severity of MHCs and outcomes of anticoagulation therapy. Design: Retrospective cohort analysis. Participants: We studied 103,897 patients on warfarin for 6 or more months cared for by the Veterans Health Administration during fiscal years 2007-2008. We identified 28,216 patients with MHCs using ICD-9 codes: anxiety disorders, bipolar disorder, depression, post-traumatic stress disorder, schizophrenia, and other psychotic disorders. Main Measures: Outcomes included anticoagulation control, as measured by percent time in the therapeutic range (TTR), as well as major hemorrhage. Predictors included different categories of MHC, Global Assessment of Functioning (GAF) scores, and psychiatric hospitalizations. Key Results: Patients with bipolar disorder, depression, and other psychotic disorders experienced TTR decreases of 2.63 %, 2.26 %, and 2.92 %, respectively ( p < 0.001), after controlling for covariates. Patients with psychotic disorders other than schizophrenia experienced increased hemorrhage after controlling for covariates [hazard ratio (HR) 1.24, p = 0.03]. Having any MHC was associated with a slightly increased hazard for hemorrhage (HR 1.19, p < 0.001) after controlling for covariates. Conclusion: Patients with specific MHCs (bipolar disorder, depression, and other psychotic disorders) experienced slightly worse anticoagulation control. Patients with any MHC had a slightly increased hazard for major hemorrhage, but the magnitude of this difference is unlikely to be clinically significant. Overall, our results suggest that appropriately selected patients with MHCs can safely receive therapy with warfarin. [ABSTRACT FROM AUTHOR]

Background: We examined the quality of adult epilepsy care using the Quality Indicators in Epilepsy Treatment (QUIET) measure, and variations in quality based on the source of epilepsy care. Methods: We identified 311 individuals with epilepsy diagnosis between 2004 and 2007 in a tertiary medical center in New England. We abstracted medical charts to identify the extent to which participants received quality indicator (QI) concordant care for individual QI's and the proportion of recommended care processes completed for different aspects of epilepsy care over a two year period. Finally, we compared the proportion of recommended care processes completed for those receiving care only in primary care, neurology clinics, or care shared between primary care and neurology providers. Results: The mean proportion of concordant care by indicator was 55.6 (standard deviation = 31.5). Of the 1985 possible care processes, 877 (44.2%) were performed; care specific to women had the lowest concordance (37% vs. 42% [first seizure evaluation], 44% [initial epilepsy treatment], 45% [chronic care]). Individuals receiving shared care had more aspects of QI concordant care performed than did those receiving neurology care for initial treatment (53% vs. 43%; X² = 9.0; p = 0.01) and chronic epilepsy care (55% vs. 42%; X² = 30.2; p < 0.001). Conclusions: Similar to most other chronic diseases, less than half of recommended care processes were performed. Further investigation is needed to understand whether a shared-care model enhances quality of care, and if so, how it leads to improvements in quality. [ABSTRACT FROM AUTHOR]

Many veterans receive rehabilitation services in Department of Veterans Affairs (VA) nursing homes. Efficient methods for the identification of active diagnoses could facilitate care planning and outcomes assessment. We set out to determine whether diagnostic data from VA databases can be used to identify active diagnoses for Minimum Data Set (MDS) assessments. We evaluated diagnoses being considered for inclusion in MDS version 3.0 and present in at least 15% of a sample of VA nursing home residents. A research nurse following a standardized protocol identified active diagnoses from the medical records of 120 residents. A clinical nurse also identified active diagnoses in 58 of these patients. Inpatient and outpatient diagnoses from the VA National Patient Care Database were identified for the past year. We calculated kappa, sensitivity, and specificity values, considering the nurses' assessments the gold standard. We found that kappa values comparing research nurses and databases were generally poor, with only 8 of the 19 diagnoses having a value >0.60. Levels of agreement between the clinical nurse and administrative data were generally similar. We conclude that VA administrative data cannot be used to accurately identify active diagnoses for nursing home residents. How best to efficiently collect these important data remains uncertain. [ABSTRACT FROM AUTHOR]

Objectives. To compare the Veterans Health Administration (VHA) with the Medicare Advantage (MA) plans with regard to health outcomes. Data Sources. The Medicare Health Outcome Survey, the 1999 Large Health Survey of Veteran Enrollees, and the Ambulatory Care Survey of Healthcare Experiences of Patients (Fiscal Years 2002 and 2003). Study Design. A retrospective study. Extraction Methods. Men 65+ receiving care in MA ( N=198,421) or in VHA ( N=360,316). We compared the risk-adjusted probability of being alive with the same or better physical (PCS) and mental (MCS) health at 2-years follow-up. We computed hazard ratio (HR) for 2-year mortality. Principal Findings. Veterans had a higher adjusted probability of being alive with the same or better PCS compared with MA participants (VHA 69.2 versus MA 63.6 percent, p<.001). VHA patients had a higher adjusted probability than MA patients of being alive with the same or better MCS (76.1 versus 69.6 percent, p<.001). The HRs for mortality in the MA were higher than in the VHA (HR, 1.26 [95 percent CI 1.23–1.29]). Conclusions. Our findings indicate that the VHA has better patient outcomes than the private managed care plans in Medicare. The VHA's performance offers encouragement that the public sector can both finance and provide exemplary health care. [ABSTRACT FROM AUTHOR]

The relative contributions of adherence and treatment intensity to blood pressure (BP) control are not well understood. The authors studied patients with uncontrolled hypertension (N=410) from 3 primary care clinics in the Veterans Affairs (VA) medical system. A questionnaire was used to assess patient adherence to therapy, and VA system pharmacy fills were used to assess the intensity of the antihypertensive regimen. At baseline, an inadequate antihypertensive regimen was implicated as the most probable reason for uncontrolled BP in a majority of patients (72%), while nonadherence could only be implicated in 13%. In multivariate longitudinal analyses, patients who had an increase in their medical treatment during the study had lower final diastolic BP levels compared with the patients who did not (−3.70 mm Hg; P <.05). While patient adherence to therapy plays a role, vigorous clinical management by the clinician is a more important contributor to BP control. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the relationship between blood pressure (BP) and all-cause mortality in subjects aged 80 and older with hypertension. DESIGN: Retrospective cohort study with 5 years of follow-up. SETTING: Ten Veterans AFFAIRS (VA) sites. PARTICIPANTS: Four thousand seventy-one ambulatory patients aged 80 and older with hypertension. MEASUREMENTS: The outcome measure was likelihood of survival during the follow-up period. Vital status was obtained from VA and Social Security files. Variables collected for adjustment in Cox regression models were baseline BP, medications, demographics, diagnoses, and health-related quality of life (HRQoL); HRQoL information was available on 1,289 subjects based on Veterans Health Study Short From-36 (SF-36) questionnaire scores. RESULTS: Subjects with higher BP (up to a systolic BP (SBP) of 139 mmHg and a diastolic BP (DBP) of 89 mmHg) were less likely to die during follow-up than subjects with lower BP. After baseline adjustments, the hazard ratio for a 10-point increase in SBP was 0.82 (95% confidence interval (CI)=0.74–0.91), up to a SBP of 139 mmHg, and for DBP was 0.85 (95% CI=0.78–0.92), up to a DBP of 89 mmHg. There was no significant association between survival and BP levels in subjects with uncontrolled hypertension. CONCLUSION: In a cohort of very old, hypertensive veterans, in subjects with controlled BPs, subjects with lower BP levels had a lower 5-year survival than those with higher BPs. This suggests that clinicians should use caution in their approach to BP lowering in this age group. [ABSTRACT FROM AUTHOR]

BACKGROUND: Poor adherence to antihypertensives has been shown to be a significant factor in poor blood pressure (BP) control. Providers' communication with patients about their medication-taking behavior may be central to improving adherence. OBJECTIVE: The goal of this study was to characterize the ways in which providers ask patients about medication taking. DESIGN: Clinical encounters between primary care providers and hypertensive patients were audiotaped at 3 Department of Veterans' Affairs medical centers. PARTICIPANTS: Primary care providers (n=9) and African-American and Caucasian patients (n=38) who were diagnosed with hypertension (HTN). APPROACH: Transcribed audiotapes of clinical encounters were coded by 2 Investigators using qualitative analysis based on sociolinguistic techniques to identify, ways of asking about medication taking. Electronic medical records were reviewed after the visit to determine the BP measurement for the day of the taped encounter. RESULTS: Four different aspects of asking about medication were identified: structure, temporality, style and content. Open-ended questions generated the most discussion, while closed-ended declarative statements led to the least discussion. Collaborative style and use of lay language were also seen to facilitate discussions. In 39% of encounters, providers did not ask about medication taking. Among patients with uncontrolled HTN, providers did not ask about medications 33% of the time. CONCLUSION: Providers often do not ask about medication-taking behavior, and may not use the most effective communication strategies when they do. Focusing on the ways in which providers ask about patients' adherence to medications may improve BP control. [ABSTRACT FROM AUTHOR]

Objective. To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control. Data Sources. Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999. Study Design. Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined. Principal Findings. Increases in antiglycemic medications occured at only 9.8percent of visits despite 39percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control ( p<.001). Conclusions. Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes. [ABSTRACT FROM AUTHOR]

To examine whether quality of care differed for veterans in Department of Veterans Affairs (VA) nursing homes and those on contract in community nursing homes and whether the VA was contracting with nursing homes providing better quality of care than other nursing homes.Observational study using administrative databases from 1997 to 1999.Ten VA and 650 community nursing homes in New York state.Four thousand seven hundred sixty-three veteran and 195,438 nonveteran residents of these nursing homes.Risk-adjusted rates of pressure ulcer development, functional decline, behavioral decline, and mortality.Veterans in VA nursing homes were significantly (P<.05) less likely to develop a pressure ulcer (odds ratio (OR)=0.63) but more likely to experience functional decline (OR=1.6) than veterans in community nursing homes. Residents of community nursing homes with VA contracts were significantly (P<.05) less likely to develop a pressure ulcer (OR=0.91) but more likely to die than residents in noncontract homes. Few nursing homes were consistently among the best or worst performers on all measures; only seven of 650 nursing homes were in the top or bottom decile and 34 in the top or bottom quartile for each measure.Large purchasers and providers of nursing home care such as the VA are unlikely to find information on quality of care useful in making decisions on whether they should“make” or“buy” care. Nursing homes performing well on one quality measure may perform poorly on another, and it is difficult to identify nursing homes that are consistently among the best or worst. Other consumers may encounter similar difficulties when using data on nursing home quality. [ABSTRACT FROM AUTHOR]

To examine the health status of elderly veteran enrollees, stratified by age group, and compare with nonveteran populations. Cross-sectional study. Outpatient. A total of 1,406,049 veteran enrollees were surveyed, and 887,775 returned the questionnaire (63.1%). Of these, 663,729 (74%) were aged 65 and older. Patient demographics, comorbid conditions, and health status, which was assessed using the Veterans 36-item short form (SF-36), a reliable and valid measure of health-related quality of life (HRQoL). Elderly veteran enrollees are a group with poor health status across all scales of the Veterans SF-36. Significant decline in HRQoL was found in patients grouped by increasing age (65–74, 75–84, and ≥85). Of the Veterans SF-36 scales, the role physical and role emotional scales and physical functioning presented the largest decrements by age group. The elderly veteran enrollees had poorer health status than older people enrolled in Medicare managed care, ranging from 0.5 to 1 standard deviations worse. Elderly veteran enrollees have substantial disease burden, as reflected by major impairments across multiple dimensions of HRQoL. These findings bear important implications for use of services, suggesting that the Veterans Health Administration will require considerable resources to provide care for its aging population. [ABSTRACT FROM AUTHOR]

OBJECTIVE — Clinical trials have demonstrated the importance of tight blood pressure control among patients with diabetes. However, little is known regarding the management of hypertension in patients with coexisting diabetes. To examine this issue, we addressed 1) whether hypertensive patients with coexisting diabetes are achieving lower levels of blood pressure than patients without diabetes, 2) whether there are differences in the intensity of antihypertensive medication therapy provided to patients with and without diabetes, and 3) whether diabetes management affects decisions to increase antihypertensive medication therapy. RESEARCH DESIGN AND METHODS — We abstracted medical records to collect detailed information on 2 years of care provided for 800 male veterans with hypertension. We compared patients with and without diabetes on intensity of therapy and blood pressure control. Intensity of therapy was described using a previously validated measure that captures the likelihood of an increase in antihypertensive medications. We also determined whether increases in antihypertensive medications were less likely at those visits in which the diabetes medications were being adjusted. RESULTS — Of the 274 hypertensive patients with diabetes, 73% had a blood pressure ≥ 140/90 mmHg, compared with 66% in the 526 patients without diabetes (P = 0.04). Diabetic patients also received significantly (P = 0.05) less intensive antihypertensive medication therapy than patients without diabetes. Less intensive therapy in diabetic patients could not be explained by clinicians being distracted by the treatment for diabetes, CONCLUSIONS — There is an urgent need to improve hypertension care and blood pressure control in patients with diabetes. Additional information is required to understand why clinicians are not more aggressive in managing blood pressure when patients also have diabetes. [ABSTRACT FROM AUTHOR]

Objective. To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care. Data Sources/Study Settings. Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database. Study Design. A cross–sectional analysis of the association among the different measures was performed. Data Collection/Extraction Methods. Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk–adjusted rates of pressure ulcer development were calculated from an administrative database. Principal Findings. Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1–point increase in QI score was associated with a 0.83 increase on the 5–point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1–point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development. Conclusions. Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain. [ABSTRACT FROM AUTHOR]

OBJECTIVES: New methods developed to improve the statistical basis of provider profiling may be particularly applicable to nursing homes. We examine the use of Bayesian hierarchical modeling in profiling nursing homes on their rate of pressure ulcer development. DESIGN: Observational study using Minimum Data Set data from 1997 and 1998. SETTING: A for-profit nursing home chain. PARTICIPANTS: Residents of 108 nursing homes who were without a pressure ulcer on an index assessment. MEASUREMENTS: Nursing homes were compared on their performance on risk-adjusted rates of pressure ulcer development calculated using standard statistical techniques and Bayesian hierarchical modeling. RESULTS: Bayesian estimates of nursing home performance differed considerably from rates calculated using standard statistical techniques. The range of risk-adjusted rates among nursing homes was 0% to 14.3% using standard methods and 1.0% to 4.8% using Bayesian analysis. Fifteen nursing homes were designated as outliers based on their z scores, and two were outliers using Bayesian modeling. Only one nursing home had greater than a 50% probability of having a true rate of ulcer development exceeding 4%. CONCLUSIONS: Bayesian hierarchical modeling can be successfully applied to the problem of profiling nursing homes. Results obtained from Bayesian modeling are different from those obtained using standard statistical techniques. The continued evaluation and application of this new methodology in nursing homes may ensure that consumers and providers have the most accurate information regarding performance. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To validate a previously derived risk-adjustment model for pressure ulcer development in a separate sample of nursing home residents and to determine the extent to which use of this model affects judgments of nursing home performance. DESIGN: Retrospective observational study using Minimum Data Set (MDS) data from 1998. SETTING: A large, for-profit, nursing home chain. PARTICIPANTS: Twenty-nine thousand and forty observations were made on 13,457 nursing home residents who were without a pressure ulcer on an index assessment. MEASUREMENTS: We used logistic regression in our validation sample to calculate new coefficients for the 17 previously identified predictors of pressure ulcer development. Coefficients from this new sample were compared with those previously derived. Expected rates of pressure ulcer development were determined for 108 nursing homes. Unadjusted and risk-adjusted rates of pressure ulcer development from these homes were also calculated and outlier identification using these two approaches was compared. RESULTS: Predictors of pressure ulcer development in the derivation sample generally showed similar effects in the validation sample. The model c-statistic was also unchanged at 0.73, but it was not calibrated as well in the validation sample. On applying the model to the nursing homes, expected rates of ulcer development ranged from 1.1% to 3.2% (P < .001). The observed rates ranged from 0% to 12.1% (P < .001). There were 12 outliers using unadjusted rates and 15 using adjusted performance. Ten nursing homes were identified as outliers using both approaches. CONCLUSIONS: Our MDS risk-adjustment model for pressure ulcer development performed well in this new sample. Nursing homes differ significantly in their expected rates of pressure ulcer development. Outlier identification also differs depending on whether unadjusted or risk-adjusted performance is evaluated. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To use the Minimum Data Set (MDS) to derive a risk-adjustment model for pressure ulcer development that may be used in assessing the quality of nursing home care. DESIGN: Perspective observational study using MDS data from 1997. SETTING: A large, for-profit, nursing home chain. PARTICIPANTS: Our unit of analysis was 39,649 observations made on 14,607 nursing home residents who were without a stage 2 or larger pressure ulcer on an index assessment. MEASUREMENTS: Pressure ulcer status was determined at an outcome assessment approximately 90 days after an index assessment. Potential predictors of pressure ulcer development were examined for bivariate associations, contributing to the development of a multivariate logistic regression model. RESULTS: A stage 2 or larger pressure ulcer developed in 2.3% of the observations. Seventeen resident characteristics were found to be associated with pressure ulcer development. These included dependence in mobility and transferring, diabetes mellitus, peripheral vascular disease, urinary incontinence, lower body mass index, and end-stage disease. A risk-adjustment model based on these characteristics was well calibrated and able to discriminate among residents with different levels of risk for ulcer development (model c-statistic = 0.73). CONCLUSION: A clinically credible risk-adjustment model with good performance properties can be developed using the MDS. This model may be useful in profiling nursing homes on their rate of pressure ulcer development. [ABSTRACT FROM AUTHOR]

Determines the usefulness of a routine, comprehensive battery of laboratory tests in a severely impaired elderly nursing home population. Patient characteristics; Yield by successive batteries; Abnormalities by panels and tests; Abnormalities by panel categories.

Assesses the importance of case-mix adjustment in interpreting differences in rates of pressure ulcer development in Department of Veterans Affairs (DVA) long-term care facilities. Predictors of ulcer development; Description of facility case mix; Predictors of pressure ulcer development.

Discusses various reports published within the issue, including one which offers evidence related to the effectiveness of pay for performance programs in the health care setting.

OBJECTIVES: To examine the influence of age and comorbidity on intensification of medical therapy for patients with poorly controlled diabetes mellitus (DM). DESIGN: Observational cohort study using data from Department of Veterans Affairs (VA) national databases. SETTING: Thirteen VA medical centers in New England, Florida, and Puerto Rico. PARTICIPANTS: Veterans (N = 5,317) with poorly controlled DM receiving regular medical care MEASUREMENTS: An increase in hypoglycemic medications, or intensification of therapy, was considered present at the visit if a new hypoglycemic medication was started or the dosage of an existing medication was increased. RESULTS: The overall rate of intensification of therapy was 20.8% (1,106/5,317). The rate of intensification was highest in the youngest patients without comorbidity (24.5%) and lowest in the oldest patients with comorbidity (15.7%) (P<.001). CONCLUSION: Rates of intensification at a single clinic visit were quite low in all groups and were lowest in older patients with comorbidity. [ABSTRACT FROM AUTHOR]

Introduction The benefits of early detection of Alzheimer's disease (AD) have become increasingly recognized. Veterans with mental health conditions (MHCs) may be less likely to receive a specific AD diagnosis compared to veterans without MHCs. We investigated whether rates of MHCs differed between veterans diagnosed with unspecified dementia (UD) vs. AD to better understand the role MHCs might play in establishing a diagnosis of AD. Materials and Methods This retrospective analysis (2015-2022) identified UD and AD with diagnostic code–based criteria. We determined the proportion of veterans with MHCs in UD vs. AD cohorts. Secondarily, we assessed the distribution of UD/AD diagnoses in veterans with and without MHCs. Results We identified 145,309 veterans with UD and 33,996 with AD. The proportion of each MHC was consistently higher in UD vs. AD cohorts: 41.4% vs. 33.2% (depression), 26.9% vs. 20.3% (post-traumatic stress disorder), 23.4% vs. 18.2% (anxiety), 4.3% vs. 2.1% (bipolar disorder), and 3.9% vs. 1.5% (schizophrenia). The UD diagnostic code was used in 84% of veterans with MHCs vs. 78% without MHCs (P  < .001). Conclusions Mental health conditions were more likely in veterans with UD vs. AD diagnoses; comorbid MHC may contribute to delayed AD diagnosis. [ABSTRACT FROM AUTHOR]

Background: Diagnostic codes can be instrumental for case identification in Alzheimer's disease (AD) research; however, this method has known limitations and cannot distinguish between disease stages. Clinical notes may offer more detailed information including AD severity and can complement diagnostic codes for case identification. Objective: To estimate prevalence of mild cognitive impairment (MCI) and AD using diagnostics codes and clinical notes available in the electronic healthcare record (EHR). Methods: This was a retrospective study in the Veterans Affairs Healthcare System (VAHS). Health records from Veterans aged 65 years or older were reviewed during Fiscal Years (FY) 2010–2019. Overall, 274,736 and 469,569 Veterans were identified based on a rule-based algorithm as having at least one clinical note for MCI and AD, respectively; 201,211 and 149,779 Veterans had a diagnostic code for MCI and AD, respectively. During FY 2011–2018, likely MCI or AD diagnosis was defined by≥2 qualifiers (i.e., notes and/or codes)≥30 days apart. Veterans with only 1 qualifier were considered as suspected MCI/AD. Results: Over the 8-year study, 147,106 and 207,225 Veterans had likely MCI and AD, respectively. From 2011 to 2018, yearly MCI prevalence increased from 0.9% to 2.2%; yearly AD prevalence slightly decreased from 2.4% to 2.1%; mild AD changed from 22.9% to 26.8%, moderate AD changed from 26.5% to 29.1%, and severe AD changed from 24.6% to 30.7% Conclusions: The relative distribution of AD severities was stable over time. Accurate prevalence estimation is critical for healthcare resource allocation and facilitating patients receiving innovative medicines. [ABSTRACT FROM AUTHOR]

Background: Clear guidelines exist to guide the dosing of direct-acting oral anticoagulants (DOACs). It is not known how consistently these guidelines are followed in practice.Methods: We studied patients from the Veterans Health Administration (VA) with non-valvular atrial fibrillation who received DOACs (dabigatran, rivaroxaban, apixaban) between 2010 and 2016. We used patient characteristics (age, creatinine, body mass) to identify which patients met guideline recommendations for low-dose therapy and which for full-dose therapy. We examined how often patient dosing was concordant with these recommendations. We examined variation in guideline-concordant dosing by site of care and over time. We examined patient-level predictors of guideline-concordant dosing using multivariable logistic models.Results: A total of 73,672 patients who were prescribed DOACS were included. Of 5837 patients who were recommended to receive low-dose therapy, 1331 (23%) received full-dose therapy instead. Of 67,935 patients recommended to receive full-dose therapy, 4079 (6%) received low-dose therapy instead. Sites varied widely on guideline discordant dosing; on inappropriate low-dose therapy, sites varied from 0 to 15%, while on inappropriate high-dose therapy, from 0 to 41%. Guideline discordant therapy decreased by about 20% in a relative sense over time, but its absolute numbers grew as DOAC therapy became more common. The most important patient-level predictors of receiving guideline-discordant therapy were older age and creatinine function being near the cutoff value.Conclusions: A substantial portion of DOAC prescriptions in the VA system are dosed contrary to clinical guidelines. This phenomenon varies widely across sites of care and has persisted over time. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Intensive blood pressure control, falls, and fractures in patients with type 2 diabetes: the ACCORD Trial" by Karen L. Margolis, Lisa Palermo Eric Vittinghoff and colleagues published in the same issue.

An obituary is presented for former physician Gene Stollerman, the former editor of the "Journal of the American Geriatrics Society".

Background: Alzheimer's disease (AD) and related dementias are progressive neurological disorders with stage-specific clinical features and challenges. An important knowledge gap is the "window of time" within which patients transition from mild cognitive impairment or mild AD to moderate or severe AD. Better characterization/establishment of transition times would help clinicians initiating treatments, including anti-amyloid therapy. Objective: To describe cognitive test score-based AD stage transitions in Veterans with AD in the US Veterans Affairs Healthcare System (VAHS). Methods: This retrospective analysis (2010–2019) identified Veterans with AD from the VAHS Electronic Health Record (EHR) notes. AD stage was based on Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), or Saint Louis University Mental Status (SLUMS) Examination scores in the EHR. Results: We identified 296,519 Veterans with cognitive test-based AD staging. Over the 10-year study, the proportion of veterans with MMSE scores declined from 24.9% to 9.5% while those with SLUMS rose from 9.0% to 17.8%; and MoCA rose from 5.0% to 25.4%. The average forward transition times between each stage were approximately 2–4 years, whether assessed by MMSE, MoCA, or SLUMS. Conclusion: The average transition time for cognitive test-based assessments of initial cognitive decline, early-stage AD, and moderate/severe AD in the VAHS is 2–4 years. In view of the short window for introducing disease-modifying therapy and the significant benefits of early treatment of AD, our data suggest a critical need for treatment guidelines in the management of AD. [ABSTRACT FROM AUTHOR]

For two decades, the U.S. government has publicly reported performance measures for most nursing homes, spurring some improvements in quality. Public reporting is new, however, to Department of Veterans Affairs nursing homes (Community Living Centers [CLCs]). As part of a large, public integrated healthcare system, CLCs operate with unique financial and market incentives. Thus, their responses to public reporting may differ from private sector nursing homes. In three CLCs with varied public ratings, we used an exploratory, qualitative case study approach involving semi-structured interviews to compare how CLC leaders (n = 12) perceived public reporting and its influence on quality improvement. Across CLCs, respondents said public reporting was helpful for transparency and to provide an "outside perspective" on CLC performance. Respondents described employing similar strategies to improve their public ratings: using data, engaging staff, and clearly defining staff roles vis-à-vis quality improvement, although more effort was required to implement change in lower performing CLCs. Our findings augment those from prior studies and offer new insights into the potential for public reporting to spur quality improvement in public nursing homes and those that are part of integrated healthcare systems. [ABSTRACT FROM AUTHOR]

Background: Early identification of individuals with mild cognitive impairment (MCI) and Alzheimer's disease (AD) is a clinical and research imperative. Use of diagnostic codes for MCI and AD identification has limitations. We used clinical notes to supplement diagnostic codes in the Veterans Affairs Healthcare System (VAHS) electronic health records (EHR) to identify and establish cohorts of Veterans recorded with MCI or AD. Methods: Targeted keyword searches for MCI ("Mild cognitive impairment;" "MCI") and AD ("Alz*") were used to extract clinical notes from the VAHS EHR from fiscal year (FY) 2010 through FY 2019. Iterative steps of inclusion and exclusion were applied until searches achieved a positive predictive value ≥ 80%. MCI and AD cohorts were identified via clinical notes and/or diagnostic codes (i.e., including Veterans recorded by "Notes Only," "Notes + Code," or "Codes Only"). Results: A total of 2,134,661 clinical notes from 339,007 Veterans met the iterative search criteria for MCI due to any cause and 4,231,933 notes from 572,063 Veterans met the iterative search criteria for AD. Over the 10-year study period, the number of clinical notes recording AD was generally stable, whereas the number for MCI more than doubled. More Veterans were identified for the MCI or AD cohorts via clinical notes than by diagnostic codes, particularly in the AD cohort. Among Veterans identified by having "Notes + Code" for MCI, the number first recorded by a code was lower than the number first recorded by a note until FY 2015 and then gradually became comparable after FY 2015. Among Veterans identified by having "Notes + Code" for AD, the number first recorded by a note was more than double the number first recorded by a code AD in each of the FYs. Conclusions: Clinical note-based identification captured more Veterans recorded with MCI and AD than diagnostic code-based identification. [ABSTRACT FROM AUTHOR]

Abstract Introduction Erectile function, an important aspect of quality of life, is gaining increased research and clinical attention in older men with hypertension. Aim To assess the cross-sectional association between blood pressure measures (systolic blood pressure [SBP]; diastolic blood pressure [DBP]; and pulse pressure [PP]) and (i) sexual activity and (ii) erectile function in hypertensive men. Methods We performed analyses of 1,255 male participants in a larger randomized clinical trial of 9,361 men and women with hypertension aged ≥50 years. Main Outcome Measures The main outcome measures were self-reported sexual activity (yes/no) and erectile function using the 5-item International Index of Erectile Function (IIEF-5). Results 857 participants (68.3%) reported being sexually active during the previous 4 weeks. The mean (SD) IIEF-5 score for sexually active participants was 18.0 (5.8), and 59.9% of the sample reported an IIEF-5 score <21, suggesting erectile dysfunction (ED). In adjusted logistic regression models, neither SBP (adjusted odds ratio = 0.998; P =.707) nor DBP (adjusted odds ratio = 1.001; P =.929) was significantly associated with sexual activity. In multivariable linear regression analyses in sexually active participants, lower SBP (β = −0.04; P =.025) and higher DBP (β = 0.05; P =.029) were associated with better erectile function. In additional multivariable analyses, lower PP pressure was associated with better erectile function (β = −0.04; P =.02). Clinical Implications Blood pressure is an important consideration in the assessment of erectile function in men with hypertension. Strengths & Limitations Assessments of blood pressure and clinical and psychosocial variables were performed using rigorous methods in this multi-ethnic and geographically diverse sample. However, these cross-sectional analyses did not include assessment of androgen or testosterone levels. Conclusions Erectile dysfunction was highly prevalent in this sample of men with hypertension, and SBP, DBP, and PP were associated with erectile function in this sample. Foy CG, Newman JC, Berlowitz DR, et al. Blood Pressure, Sexual Activity, and Erectile Function in Hypertensive Men: Baseline Findings from the Systolic Blood Pressure Intervention Trial (SPRINT). J Sex Med 2019;16:235–247. [ABSTRACT FROM AUTHOR]

A response by Sarwat I. Chaudry, Dan R. Berlowitz, and John Concato to the letter to the editor about their article "Quality of Care for Older Patients with Diabetes Mellitus with Comorbidity" published within the issue is presented.

Editorial. Comments on two articles on pressure ulcer preventive care in the U.S., published in a 2003 issue of the 'Journal of the American Geriatrics Society.' Need for the medical community to commit to a six-sigma standard of quality improvement; Key processes of care; Difficulties in detecting the performance of routine processes of care; Organization of pressure ulcer care.

Background: There has been concern about the growing off-label use of testosterone. Understanding the context within which testosterone is prescribed may contribute to interventions to improve prescribing.Objective: To evaluate patient characteristics associated with receipt of testosterone.Design: Cross-sectional.Setting: A national cohort of male patients, who had received at least one outpatient prescription within the Veterans Affairs (VA) system during Fiscal Year 2008- Fiscal Year 2012.Participants: The study sample consisted of 682,915 non-HIV male patients, of whom 132,764 had received testosterone and a random 10% sample, 550,151, had not.Main Measures: Conditions and medications associated with testosterone prescription.Key Results: Only 6.3% of men who received testosterone from the VA during the study period had a disorder of the testis, pituitary or hypothalamus associated with male hypogonadism. Among patients without a diagnosed disorder of hypogonadism, the use of opioids and obesity were the strongest predictors of testosterone prescription. Patients receiving >100 mg/equivalents of oral morphine daily (adjusted odds ratio = 5.75, p < 0.001) and those with body mass index (BMI) >40 kg/m2 (adjusted odds ratio = 3.01, p < 0.001) were more likely to receive testosterone than non-opioid users and men with BMI <25 kg/m2. Certain demographics (age 40-54, White race), comorbid conditions (sleep apnea, depression, and diabetes), and medications (antidepressants, systemic corticosteroids) also predicted a higher likelihood of testosterone receipt, all with an adjusted odds ratio less than 2 (p < 0.001).Conclusions: In the VA, 93.7% of men receiving testosterone did not have a diagnosed condition of the testes, pituitary, or hypothalamus. The strongest predictors of testosterone receipt (e.g., obesity, receipt of opioids), which though are associated with unapproved, off-label use, may be valid reasons for therapy. Interventions should aim to increase the proportion of testosterone recipients who have a valid indication. [ABSTRACT FROM AUTHOR]

Background: We examined the quality of adult epilepsy care using the Quality Indicators in Epilepsy Treatment (QUIET) measure, and variations in quality based on the source of epilepsy care.Methods: We identified 311 individuals with epilepsy diagnosis between 2004 and 2007 in a tertiary medical center in New England. We abstracted medical charts to identify the extent to which participants received quality indicator (QI) concordant care for individual QI's and the proportion of recommended care processes completed for different aspects of epilepsy care over a two year period. Finally, we compared the proportion of recommended care processes completed for those receiving care only in primary care, neurology clinics, or care shared between primary care and neurology providers.Results: The mean proportion of concordant care by indicator was 55.6 (standard deviation = 31.5). Of the 1985 possible care processes, 877 (44.2%) were performed; care specific to women had the lowest concordance (37% vs. 42% [first seizure evaluation], 44% [initial epilepsy treatment], 45% [chronic care]). Individuals receiving shared care had more aspects of QI concordant care performed than did those receiving neurology care for initial treatment (53% vs. 43%; X(2) = 9.0; p = 0.01) and chronic epilepsy care (55% vs. 42%; X(2) = 30.2; p < 0.001).Conclusions: Similar to most other chronic diseases, less than half of recommended care processes were performed. Further investigation is needed to understand whether a shared-care model enhances quality of care, and if so, how it leads to improvements in quality. [ABSTRACT FROM AUTHOR]

Introduction Sexual function, an important component of quality of life, is gaining increased research and clinical attention in older women with hypertension. Aim To assess the association between systolic blood pressure (SBP) and other variables, and sexual activity and sexual dysfunction in hypertensive women. Methods Baseline analysis of 635 women participants of a larger randomized clinical trial of 9361 men and women. Main Outcome Measures Self-reported sexual activity (yes/no), and sexual function using the Female Sexual Function Inventory (FSFI). Results 452 participants (71.2%) reported having no sexual activity during the previous 4 weeks. The mean (SD) FSFI score for sexually active participants was 25.3 (6.0), and 52.6% of the sample reported a FSFI score ≤26.55 designating sexual dysfunction. In logistic regression models, SBP was not significantly associated with sexual activity (AOR = 1.002; P > .05). Older age (AOR = 0.95, P < .05), and lower education (AOR for < high school vs college degree = 0.29, P < .05) were associated with lower odds of being sexually active, as was living alone versus living with others (AOR = 0.56, P < .05). Higher weekly alcohol consumption was associated with increased odds of being sexually active (AOR = 1.39; P < .05). In logistic regression models among sexually active participants, SBP was not associated with sexual dysfunction (AOR = 1.01; P > .05). Higher depressive symptoms from the Patient Health Questionnaire-9 (PHQ-9) was associated with higher odds of sexual dysfunction (AOR = 1.24, P < .05), as was increased number of physical comorbidities (AOR = 1.25, P < .05). Diuretic use was associated with lower odds of being sexually active in participants with chronic kidney disease (AOR = 0.33, P < .05). Conclusion Younger age, higher education, living with others, and higher weekly alcohol consumption were significantly associated with higher odds of being sexually active in a sample of middle-aged and older women with hypertension. Increased depressive symptoms and increased physical comorbidities were significantly associated with increased odds of sexual dysfunction. SBP was not significantly associated with sexual activity or sexual dysfunction. [ABSTRACT FROM AUTHOR]

A reply by the author is presented in response to letters to the editor on the article "Inadequate management of blood pressure in a hypertensive population," seen in the December 31, 1998 issue.

Background: Many patients with hypertension have inadequate control of their blood pressure. Improving the treatment of hypertension requires an understanding of the ways in which physicians manage this condition and a means of assessing the efficacy of this care. Methods: We examined the care of 800 hypertensive men at five Department of Veterans Affairs sites in New England over a two-year period. Their mean (±SD) age was 65.5±9.1 years, and the average duration of hypertension was 12.6±5.3 years. We used recursive partitioning to assess the probability that antihypertensive therapy would be increased at a given clinic visit using several variables. We then used these predictions to define the intensity of treatment for each patient during the study period, and we examined the associations between the intensity of treatment and the degree of control of blood pressure. Results: Approximately 40 percent of the patients had a blood pressure of ≥160/90 mm Hg despite an average of more than six hypertension-related visits per year. Increases in therapy occurred during 6.7 percent of visits. Characteristics associated with an increase in antihypertensive therapy included increased levels of both systolic and diastolic blood pressure at that visit (but not previous visits), a previous change in therapy, the presence of coronary artery disease, and a scheduled visit. Patients who had more intensive therapy had significantly (P<0.01) better control of blood pressure. During the two-year period, systolic blood pressure declined by 6.3 mm Hg among patients with the most intensive treatment, but increased by 4.8 mm Hg among the patients with the least intensive treatment. Conclusions: In a selected population of older men, blood pressure was poorly controlled in many. Those who received more intensive medical therapy had better control. Many physicians are not aggressive enough in their approach to hypertension. (N Engl J Med 1998;339:1957-63.) [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about pressure ulcers.

Introduction: Uncertainty surrounding the accurate assessment of the early-stage Alzheimer's disease (AD) may cause delayed care and inappropriate patient access to new AD therapies. Methods: To analyze clinical assessments of patients with AD in the Veteran's Affairs (VA) Healthcare System and evaluate concordance between subjective and objective assessments, we processed clinical notes extracted by text integration utilities between April 1, 2008 and October 14, 2021. Veterans who had mild, moderate, or severe AD with clinical notes documenting both clinician's judgement of AD severity and objective test scores from the Mini-Mental State Examination or the Montreal Cognitive Assessment were included. Using clinician-defined severity cohorts, we determined concordance between the clinician's (subjective) assessments and the test-derived (objective) assessments of AD severity. Concordance was assessed over time and by selected symptoms and comorbidities, as well as healthcare system factors. Results: A total of 8888 notes were initially extracted; the final analysis sample included 7514 notes corresponding to 4469 unique patients (mean [standard deviation] age of 78 [9] years; 96.5% male; 77.8% White). Subjective and objective assessments were concordant in approximately half (53%) of overall notes. In the mild Alzheimer's cohort, patients were assessed to have more severe disease by objective test scores in 40% of notes. Concordance varied about 21–73%, 47–58%, and 40–64% across symptoms/comorbidities, clinician types, and Veteran's Integrated Service Networks, respectively. The proportion of concordant notes was higher in visits to dementia (61%) instead of non-dementia clinics (53%). Conclusions: We found higher concordance between clinician's assessment and test-based assessment of Alzheimer's disease severity in dementia specialty clinics. Discordance is especially high for the subjectively assessed mild AD cohort where objective assessments showed a higher severity level in 40% of notes. These data indicate a critical need for improved understanding of clinical assessments and decision-making to identify appropriate patients for anti-amyloid therapy. [ABSTRACT FROM AUTHOR]

The article discusses a study which examined the relationship between follow-up intervals after obtaining an in-range international normalized ratio (INR) and anticoagulation control. The researchers investigated 104,451 patients who were receiving anticoagulation therapy from 100 anticoagulation clinics in the U.S. Veterans Health Administration. It was found that there was a link between shorter intervals and better anticoagulation control.

Standard approaches for determining weights when calculating a composite measure of health care quality from individual quality indicators (QIs) include equal weighting, opportunity-based weights, and judgment-based weights. Benefit-of-the-doubt approaches have not been used in the health services area, though one has been used to calculate composite measures for profiling countries. Underlying these approaches is the assumption that relative performance on a set of indicators is, at least to some extent, a revealed preference by the organizational unit about the relative importance of the indicators. A benefit-of-the-doubt approach recognizes these revealed preferences by assigning higher weights to indicators on which performance is better and lower weights to indicators on which performance is poorer. We consider two benefit-of-the-doubt approaches. The first uses simple linear programming (LP) models; the second uses data envelopment analysis (DEA), the way in which the benefit-of-the-doubt approach has been previously implemented. In both cases, constraints are added to limit weight adjustments to some percentage of policy-determined baseline weights. Using both standard and benefit-of-the-doubt approaches, composite scores are calculated from data on five QIs from 32 Department of Veterans Affairs (VA) nursing homes. We examine the tradeoff between the level of allowable weight adjustment and impact on facility rankings. If weights are constrained to be within 75% of baseline weights, all approaches identify pretty much the same high performing facilities. Weights from benefit-of-the-doubt approaches, because they are able to reflect local preferences and conditions, should be attractive to facilities and, in a collaborative environment, to policy makers. [ABSTRACT FROM AUTHOR]

The incidence of epilepsy in patients aged >60 years is higher than in any other period of life. Yet, until recently, what was known about the treatment of older patients with epilepsy has been inferred from studies in younger patients. A growing body of clinical evidence focused exclusively on the elderly suggests that, while some issues are similar for older and younger adults, older patients with epilepsy may require even more attention regarding antiepileptic drug (AED) selection than younger patients. This article reviews published guidelines and recommendations to identify explicit recommendations for use of specific AEDs in the elderly, and assesses the extent to which those recommendations have been adopted in clinical practice.We found that while one systematically derived guideline stated that lamotrigine may be a good choice for older patients because of its favourable adverse effect profile, only clinical recommendations based on expert opinion explicitly identified AEDs that are more and less appropriate for use in the elderly. Examination of published studies describing recent AED-prescribing patterns suggests that clinical recommendations have been, at best, slowly adopted. This observation is exemplified by the fact that older patients newly diagnosed with epilepsy are still prescribed phenobarbital – a drug identified as suboptimal in 1985.In order to better understand the delay in adopting clinical recommendations, we examine these findings in light of diffusion of innovations theory, a theory that has been used to understand dissemination of other new medical technologies. According to this theory, while it is too early to suggest that use of second-generation AEDs in the elderly has been delayed, the continued use of phenobarbital in older patients newly diagnosed with epilepsy represents a serious delay in adoption of recent guidelines. Delays may be related to lack of knowledge by primary care clinicians and emergency room physicians (who frequently treat older patients with epilepsy), lack of ‘opinion leaders’ in primary care and perhaps general neurology, clinicians’ focus on seizure control as the primary endpoint in treating patients with epilepsy, and difficulties in changing long-standing prescribing patterns.Research targeting barriers to more appropriate prescribing is needed to determine appropriate strategies for changing AED prescribing practices in the elderly. [ABSTRACT FROM AUTHOR]