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A review of the evidence underlying disease-specific guidelines helps to explain the origin of the tension between the standardized treatment of diseases and the individualized care of patients with multiple conditions. The successful translation of disease guidelines into prescriptions that meet the needs of individuals depends on the use of information technology to collect, analyze and present complex data.

Patient-centered, accountable care has garnered increased attention with the passage of the Affordable Care Act and new Medicare regulations. This case study examines a care model jointly developed by a provider and a payer that approximates an accountable care organization for a Medicare Advantage population. The collaboration between Aetna and NovaHealth, an independent physician association based in Portland, Maine, focused on shared data, financial incentives, and care management to improve health outcomes for approximately 750 Medicare Advantage members. The patient population in the pilot program had 50 percent fewer hospital days per 1,000 patients, 45 percent fewer admissions, and 56 percent fewer readmissions than statewide unmanaged Medicare populations. NovaHealth's total per member per month costs across all cost categories for its Aetna Medicare Advantage members were 16.5 percent to 33 percent lower than costs for members not in this provider organization. Clinical quality metrics for diabetes, ischémie vascular disease, annual office visits, and postdischarge follow- up for patients in the program were consistently high. The experience of developing and implementing this collaborative care model suggests that several components are key, including robust data sharing and information systems that support it, analytical support, care management and coordination, and joint strategic planning with close provider-payer collaboration. [ABSTRACT FROM AUTHOR]

Systolic hypertension (SH) is a major public health concern predominantly affecting older persons. A key message of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) is that SH is a much more important cardiovascular disease risk factor than diastolic hypertension, particularly in older persons. Consequently, aggressive control of elevations of systolic blood pressure (SBP) is recommended. Despite increasing attention, SH is on the rise: isolated elevations of SBP in a national sampling of Veteran''s Administration patients have increased from 57% in 1990 to 1995 to 76% of patients in 1999. This article considers several clinically pertinent issues, including the evidence for treating older patients with elevations in SBP, treating SH in the “oldest old” (those aged >85 years), and how aggressively these patients should be treated. In addition, issues regarding clinical decision making in older patients with SH are discussed. [Copyright &y& Elsevier]

BACKGROUND: Medication decision making is complex, particularly for older patients with multiple conditions for whom benefits may be uncertain and health priorities may be variable. While patient input would seem important in the face of this uncertainty and variability, little is known about older patients' views of involvement in medication decision making. OBJECTIVE: To explore the views of older adults regarding participation in medication decision making. DESIGN: Qualitative study. PARTICIPANTS: Fifty-one persons at least 65 years old who consumed at least one medication were recruited from 3 senior centers and 4 physicians' offices. APPROACH: One-on-one interviews were conducted to uncover participants' perceptions of medication-related decision making through semistructured, open-ended questions. Themes were compared according to the constant comparative method of analysis. RESULTS: The predominant theme that emerged was the variability in perceptions concerning whether it was possible or desirable for patients to participate in prescribing decisions. For some participants, involvement was limited to sharing information. Physician and system factors that were felt to facilitate or impede patient participation included communication skills, the expanding number of medications available, multiple physicians prescribing for the same patient, and a focus on treating numbers. Perceived lack of knowledge, low self-efficacy, and fear were the patient factors mentioned. Both the presence and absence of trust in the prescribing physician were seen as alternatively impeding and enhancing patient participation. Only 1 participant explicitly mentioned patient preference, a cornerstone of shared decision making. CONCLUSIONS: While evolution to greater patient involvement in medication decision making may be possible, and desirable to some older patients, findings suggest that the transition will be challenging. [ABSTRACT FROM AUTHOR]

Presents the comments made by readers of the periodical 'Archives of Internal Medicine.' Association of diphenhydramine use with adverse effects in hospitalized older patients; Use of anticoagulant therapy to reduce mortality of acute pulmonary embolism; Educational exercises for mental fitness and physical exercise for healthy functions.