Championing Care for Older Adults
“I was instantly attracted to working on Choosing Wisely® from the minute I heard about the opportunity,” said Ariel Green, MD, MPH, assistant professor of medicine at the Johns Hopkins University School of Medicine.
Dr. Green was recently recognized as a Choosing Wisely Champion by the American Geriatrics Society (AGS) for her work in advancing the campaign. Announced earlier this year, the Champions program is an initiative to recognize clinicians who are leading efforts to reduce overuse and waste in medicine. More than a dozen leading medical specialty societies have committed to participate in the program.
As a member of the AGS Clinical Practice & Models of Care Committee, Dr. Green played a leading role in developing AGS Choosing Wisely recommendations, which she says she incorporates into her practice on a daily basis. She works closely with patients and their family members to learn about their goals and creates plans that ensure they get the most appropriate care.
“As a geriatrician I am constantly seeing patients who are being harmed by overtreatment. I think it’s important that Choosing Wisely is addressing it, and giving clinicians tools to talk about overtreatment with their patients and family members,” she said.
Dr. Green often addresses the AGS recommendation, “Don’t prescribe a medication without conducting a drug regimen review” in her very first visit with patients.
“I’ll go over each medicine, why it was started, when it was started, whether they’re benefiting from it, side effects and interactions with other medications,” she said.
She also discusses glycemic control management with patients with diabetes and their families. AGS recommends moderate glycemic control, stating, “There is no evidence that using medications to achieve tight glycemic control in most older adults with type-2 diabetes is beneficial.”
“We’ve done a really good job of teaching patients about tightly controlling their diabetes for so many years, and they become used to it, often working really hard over decades at keeping their diabetes well-controlled. So it’s a surprise to a lot of people when they come to the geriatrician and I tell them they don’t need to do that anymore. And a lot of times they benefit because they have side effects from low blood sugar they didn’t even realize,” she said.
Dr. Green developed an interest in reducing unnecessary care early in her career.
During her geriatrics fellowship she looked at the use of implantable cardioverter-defibrillators (ICD) in older adults, and the role of shared decision-making with patients and families. She found that about 10 percent of older adults who received ICDs were frail or had dementia, and many of those patients died within a year of receiving their ICD.
Several societies have published on this topic, including the Heart Rhythm Society’s recommendation “Don’t implant an ICD for the primary prevention of sudden cardiac death in patients unlikely to survive at least one year due to con-cardiac comorbidity.”
“This is one of those scenarios when you really need to question if this invasive therapy is in line with patient preferences and the evidence base. Do the benefits outweigh the harms?” she said.
In another research project, Dr. Green asked older adult patients who had ICDs to complete a questionnaire that helps predict if they’d experience significant functional decline or die within two years. They were then asked if they would make the same choice again to get a defibrillator implanted given their current health. The vast majority said they would, despite being functionally impaired and having poor prognosis.
“That just highlights the need for Choosing Wisely, and the need to foster a discussion about evidence-based medicine and situations in which harms may outweigh benefits.”
In addition to incorporating Choosing Wisely in her practice, Dr. Green has helped educate her colleagues, patients and families through local, national and international meetings, including the Anne Arundel County Caregivers Association, a plenary at the AGS annual meeting and the International Symposium of Geriatrics and Gerontology in Mexico.
While Dr. Green is optimistic about Choosing Wisely and its potential to improve care, she recognizes there is still work to be done.
“Whenever you have a recommendation that goes against years of teaching, it can be challenging to implement,” she said. “We know a lot from research about when to start things. We’re not so good at knowing when to stop.”
Members of the American Geriatrics Society submitted nominations for Choosing Wisely Champions beginning in February 2016. The panel of experts responsible for the AGS Choosing Wisely recommendations reviewed each candidate’s application before selecting the Society’s final Champions in advance of the AGS 2016 Annual Scientific Meeting.
