November 2021

GERIATRICS

CHOOSING UNWISELY: DISSEMINATION NEEDS OF PRIMARY CARE PROVIDERS OF PATIENTS WITH ALZHEIMER'S DISEASE

Featuring: ​Lee Ann Lindquist, MD, MPH, MBA ​

INTRODUCTION
Choosing Wisely is a well-known campaign to disseminate evidence-based clinical practices to providers and patients to drive care decisions with geriatrics recommendations released in 2013. In December of 2019, Lee A Lindquist, MD, MPH, MBA, section chief of Geriatric Medicine in the Department of Medicine, George M. Eisenberg Research Professor of Geriatric Medicine and associate professor of General Internal Medicine and Geriatrics, Alice Kerr, MD, Health System Clinician of Medicine (General Internal Medicine and Geriatrics), Theresa Rowe, MD, MPH, assistant professor of Medicine (General Internal Medicine and Geriatrics), and Sara Bradley, MD, associate professor of Medicine (General Internal Medicine and Geriatrics) and Medical Education, aimed to determine what the dissemination needs of primary care providers were towards these recommendations. 

METHODS
We developed common clinical scenarios with follow-up survey questions, relative to the care of people with Alzheimer's disease (AD) and utilizing Choosing Wisely geriatrics recommendation. The survey was distributed online to a national cohort of providers. Providers were also asked to rate their confidence level and rationale for clinical choices mixed methodology with constant comparative analysis utilized for qualitative responses.

RESULTS
Nationally from 41/50 states, 211 providers responded, 72% female, with occupations of physician (36%, 77), advanced practice nurse (50%, 106), and physician assistant (13%, 28), with family practice (63%, 142) and internal medicine (20%, 42) the most prominent fields. Results revealed erroneous geriatric practices, including:

  1. Checking urinalysis for mental-status changes (55%, 116)
  2. Treating asymptomatic bacteria with unnecessary antibiotics (59%, 124)
  3. Placement of gastric tubes in end-stage dementia (11%, 23)

Qualitative analysis of rationale for incorrect responses revealed misconceptions      (e.g., feeding tube would help avoid aspiration). Confidence levels were high among providers as 75.9% related themselves as above average, yet did not correlate to  clinical errors.

​Error and Incorrect Rationale

Choosing Wisely Guideline:
Don't recommend percutaneous feeding tubes in patients with advanced dementia.
Error/Wrong Action:
Ordering placement of feeding tube in patient with end-stage AD
Example Error Rationale Quote:
  • Safety/Feeding tubes decrease risk of aspiration (which it does not)
  • Concern about aspiration pneumonia
  • Might prevent reflux disease

Choosing Wisely Guideline:
Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary symptoms present.
Error/Wrong Action:
Starting antibiotic in patients with AD who has asymptomatic bacteriuria
Example Error Rationale Quote:
  • Prevent further septic event
  • Avoid losing patient to follow-up
  • I would start antibiotics because of age

Choosing Wisely Guideline:
Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation.
Error/Wrong Action:
Prescribe benzodiazepine
Example Error Rationale Quote:
  • Newer alternatives are not as safe

Choosing Wisely Guideline:
Don't prescribe a medication without conducting a drug regimen review.
Error/Wrong Action:
Not stopping medication/Avoid de-prescribing
Example Error Rationale Quote:
  • Very risky to take away medications
  • Too many other clinical things to address and this is not a medical priority to me
  • Patient will forget to stop it

DISCUSSION 
Choosing Wisely geriatrics recommendations are not being followed by providers in the care of patients with AD. Highly confident providers made errors similar to lower confident providers.

FINANCIAL DISCLOSURE
Dr. Lindquist receives funding through the NIA R01AG05877, NIA R01AG06842, and the Claude D. Pepper Older Americans Independence Center (OAIC) at Northwestern University [NIA P300AG059988].
Lee Ann Lindquist, MD, MPH, MBA is a Geriatrician and Chief of Geriatrics in the Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine. Her patient-centered research focuses on helping older adults age-in-place, when they develop Alzheimer’s disease, through home and community-based resources and supporting caregivers. She has extensive experience partnering in research with community organizations and community members for recruitment, study implementation, data collection, and dissemination. ​
Emily J Rogalski, PhD headshot
Alice Kerr, MD, Health System Clinician of Medicine (General Internal Medicine and Geriatrics).​​
Emily J Rogalski, PhD headshot
Theresa Rowe, MD, MPH, assistant professor of Medicine (General Internal Medicine and Geriatrics).​​
Emily J Rogalski, PhD headshot
Sara Bradley, MD, associate professor of Medicine (General Internal Medicine and Geriatrics) and Medical Education.​​

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