Diversity, Equity and Inclusion in an Age-Friendly Health System

The Age-Friendly Health Systems (AFHS) initiative uses a 4Ms framework to encourage patient-centered care for older adults. Many health systems have implemented the core elements of AFHS – What Matters, Mentation (Cognition and Depression), Medications, and Mobility – with the goal to uniformly apply these elements to all patients 65 years and older. However, equity in AFHS delivery has not yet been examined. Five diversity, equity, and inclusion (DEI) factors, including gender, race, ethnicity, preferred language and MyChart activation, were cross-sectionally analyzed against the 4Ms framework for patients seen (in person or virtual visit) in an academic internal medicine clinic between April 2020 and April 2021 (N= 3370) using two-way contingency tables. Preferred language, gender, and MyChart activation yielded significant pairings with the 4M metrics. For the AFHS What Matters metric, females were 1.10 times more likely than males and English-speaking patients were 1.67 times more likely than non-English speaking patients to receive advance care planning (p <0.01). Females and patients with MyChart activation were about 2.0 times more likely to have a high-risk medication on their medication list compared to males and patients without MyChart activation (p <0.01). MyChart activation was also significantly associated with cognitive screening. Patients with MyChart activation were 1.09 times more likely than patients without MyChart activation to get cognitive screening (p <0.001). This study, the first to incorporate demographic data, into AFHS quality measures, suggest a need to develop best practices for equitable Age-Friendly care at the clinical team and the institutional policy level.

The Severity of Muscle Performance Deterioration in Sarcopenia Correlates With Circulating Muscle Tissue-Specific miRNAs

Sarcopenia is defined as an age-associated loss of skeletal muscle function and muscle mass and is common in older adults. Sarcopenia as a disease is currently of interest not only to orthopedists and surgeons but also to internists, endocrinologists, rheumatologists, cardiologists, diabetologists, gynaecologists, geriatricians and paediatricians. In cooperation with the 5th Internal Medicine Clinic, we, as a unit of clinical research, aimed to describe a sarcopenic specific miRNA expression profile for disease diagnostics and classification of the severity of muscle performance deterioration. This study included a total of 80 patients (age 55-86 years) hospitalized at the V. Internal medicine clinic of LFUK and UNB with different severity of muscle performance deterioration. The study participants were evaluated and classified according to short physical performance battery score (SPPB). In this study, we investigated the role of circulating miRNAs in sarcopenia in the elderly. We hypothesized that sarcopenia effects the expression of muscle tissue-specific miRNAs (MyomiRNAs), which could be potentially reflected in the blood plasma miRNA expression profile. The expression of specific circulating miRNAs in patients with different muscle performances was analyzed. Patients’ blood plasma was evaluated for the expression of myomiRNAs: miRNA-29a, miRNA-29b, miRNA-1, miRNA-133a, miRNA-133b, miRNA-206, miRNA-208b and miRNA-499, and the data were correlated with diagnostic indicators of the disease. We showed a specific sarcopenia miRNA profile that could be considered a possible biomarker for the disease. Patients with low muscle performance showed increased miRNA-1, miRNA-29a and miRNA-29b expression and decreased for the miRNA-206, miRNA-133a, miRNA-133b, miRNA-208b and miRNA-499 expression. We show that the severity of muscle performance deterioration in sarcopenia correlates with specific miRNA expression. We also propose the profile of miRNAs expression in blood plasma as a specific biomarker for sarcopenia diagnostics. Future clinical studies will be necessary to eventually naturally have to elucidate the underlined molecular mechanism responsible for specific miRNAs expression in sarcopenia pathology and progression of the disease.

Polypharmacy in the Management of Arterial Hypertension—Friend or Foe?

Background and Objectives: Polypharmacy is associated with drug–drug or food–drug interactions that may pose treatment difficulties. The objective of the study was to investigate the use of polypharmacy in hypertensive patients hospitalized in the Internal Medicine Clinic of a European referral hospital. Materials and Methods: We conducted a retrospective chart review study on patients identified by a database search of discharge diagnoses to assess the use of polypharmacy and identify potential drug-drug and food-drug interactions. Results: In total, 166 hypertensive patients (68.46 ± 12.70 years, range 42–94 years) were compared to 83 normotensive subjects (67.82 ± 14.47 years, range 22–94 years) who were hospitalized in the clinic during the same period. Polypharmacy was more common in hypertensive versus normotensive subjects (p = 0.007). There were no differences in terms of age, as well as major (0.44 ± 0.77 versus 0.37 ± 0.73 interactions/patient, p = 0.52) and minor (1.25 ± 1.50 versus 1.08 ± 1.84 interactions/patient, p = 0.46) drug–drug interactions between patients with and without hypertension. The mean number of drug–drug interactions (6.55 ± 5.82 versus 4.93 ± 5.59 interactions/patient, p = 0.03), moderate drug–drug interactions (4.94 ± 4.75 versus 3.54 ± 4.17, p = 0.02) and food–drug interactions (2.64 ± 1.29 versus 2.02 ± 1.73, p = 0.00) was higher in patients with hypertension versus their counterparts. Conclusions: The present study reinforces that polypharmacy is a serious concern in hypertensive patients, as reflected by the high number of potentially harmful drug–drug or food–drug interactions. We recorded higher numbers of comorbidities, prescribed drugs, and moderate drug–drug/food–drug interactions in hypertensive versus normotensive patients. A strategy to evaluate the number of discharge medications and reduce drug–drug interactions is essential for the safety of hypertensive patients.

Patient Characteristics and Utilization of an Online Patient Portal in a Rural Academic General Internal Medicine Practice

Background: Online patient portals have the potential to improve patient engagement and health care outcomes. This is especially true among rural patient populations that may live far from their health care providers and have transportation barriers to access care. This study compared the characteristics of active users of an online patient portal to non-users and assessed utilization among users in a rural academic primary care clinic to identify disparities in adoption and use. Methods: We conducted a cross sectional study of 28,028 patients in a general internal medicine clinic between June 2019 and May 2020 to assess a) characteristics of patients who had an online patient portal account and used the patient portal compared to those who did not register for an account, and b) the frequency of use of the patient portal (number of logons and number of messages sent and received) by patients over the study period. We compared results based on demographic characteristics, focusing on gender, age, race, presence or absence of nine chronic illnesses, smoking status, and BMI. Results: In the study cohort of 28,028 patients, 82% were active users of the patient portal. Females, patients aged 41-65, and non-smokers were more likely to use the portal than their counterparts. In total, patients with eight out of nine chronic illness groups studied (heart failure, cerebrovascular disease, history of a myocardial infarction, peripheral vascular disease, and renal disease) were less likely to use the patient portal than patients without these chronic conditions. On average, patients log onto the patient portal 25 times per year and send and receive 6 messages to and from the clinic. We found that females, patients older than 65, former smokers and obese patients logged on and sent and received more messages compared to the overall cohort. Although the sample size was small, on average Black patients logged onto the patient portal 19 times and sent and received 3.6 messages compared to White patients who logged on 25 times with 5.8 messages on average over the yearlong study period.Conclusions: In a rural academic internal medicine clinic, female patients, aged 41-65, non-smokers, and those without certain chronic conditions were more likely to use an online patient portal. Recognizing and addressing barriers to patient portal use is essential for robust and sustained patient portal uptake and ensuring that the benefits of portal use are equally distributed among all patients.

Value of the Clinical Pharmacist Interventions in the Application of the American College of Cardiology (ACC/AHA) 2018 Guideline for Cholesterol Management

The study aims to examine the extent of implementing the ACC/AHA cholesterol guideline and its updates in practice as well as the role of clinical pharmacists in making such guidelines effective. A cross-sectional observational study was conducted on 272 adult patients who visited the hospital internal medicine clinic in the UAE and were candidates for statin therapy based on the 2018 ACC/AHA guidelines for cholesterol management. Clinical pharmacist interventions were determined. The chi-square test was used to compare compliance with the guidelines before and after clinical pharmacist interventions. Compliance with the recommendations for cholesterol management was significantly improved from 60.3% to 92.6% (X2=79.1, p=0.0001) after clinical pharmacist interventions. Among patients who were on statin therapy, the percentage of those who were on proper statin intensity increased significantly from 47.6% to 94.4% (X2=72.5, p=0.0001). The combination of statins with nonstatin therapies such as ezetimibe and PCSK9 inhibitors increased from 8.5% to 30.6% (X2=95, p<0.0001) and from 0.0% to 1.6% (X2=6, p=0.014), respectively. The use of other lipid-lowering agents was diminished from 14.6% to 3.2% (X2=19.2, p<0.0001). Collaboration between physicians and clinical pharmacists is a crucial strategy to achieve better health outcomes among patients suffering from dyslipidemia.

Role of vitamin D in patients with cardiac arrhythmias (atrial fibrillation). Personalization of nutrition

Despite advances in the diagnosis and treatment of various forms of cardiac arrhythmias, atrial fibrillation (AF) remains a serious problem in the internal medicine clinic, especially acute in gerontology. Prevention of the development of cardiac arrhythmias is an important medical and social task. Adequate nutrition plays an important role in the cardiovascular diseases prophylaxis. At the same time, a deficiency of vitamins and minerals, including vitamin D, can create a pathogenetic basis for the development of arrhythmias. Experimental and clinical studies have demonstrated the effect of vitamin D on the mechanisms underlying the formation of AF. Screening for vitamin D deficiency in cardiac patients should become routine. Correcting vitamin D deficiencies must be personalized. Further clinical trials are needed to investigate the clinical endpoints (morbidity and mortality) of vitamin D supplementation in arrhythmology.

Impact of a medical scribe on clinical efficiency and quality in an academic general internal medicine practice

Background Scribes have been proposed as an intervention to decrease physician electronic health record (EHR) workload and improve clinical quality. We aimed to assess the impact of a scribe on clinical efficiency and quality in an academic internal medicine practice. Methods Six faculty physicians worked with one scribe at an urban academic general internal medicine clinic April through June 2017. Patient visits during the 3 months prior to intervention (baseline, n = 789), unscribed visits during the intervention (concurrent control, n = 605), and scribed visits (n = 579) were included in the study. Clinical efficiency outcomes included time to close encounter, patient time in clinic, and number of visits per clinic session. Quality outcomes included EHR note quality, rates of medication and immunization review, population of patient instructions, reconciliation of outside information, and completion of preventative health recommendations. Results Median time to close encounter (IQR) was lower for scribed visits [0.4 (4.8) days] compared to baseline and unscribed visits [1.2 (5.9) and 2.9 (5.4) days, both p < 0.001]. Scribed notes were more likely to have a clear history of present illness (HPI) [OR = 7.30 (2.35–22.7), p = 0.001] and sufficient HPI information [OR = 2.21 (1.13–4.35), p = 0.02] compared to unscribed notes. Physicians were more likely to review the medication list during scribed vs. baseline visits [OR = 1.70 (1.22–2.35), p = 0.002]. No differences were found in the number of visits per clinic session, patient time in clinic, completion of preventative health recommendations, or other outcomes. Conclusions Working with a scribe in an academic internal medicine practice was associated with more timely documentation.