Is Geriatrics-focused Primary Care (GeriPACT) Better? Nicki Hastings, Kristie Hsu, and Ken Covinsky

Eric 00:06

This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And Alex, who do we have with us today?

Alex 00:16

Today we are delighted to welcome Nicki Hastings, who is a geriatrician in chief of the Division of General Medicine at Duke in the great state of North Carolina. Nicki, welcome to the GeriPal Podcast.

Nicki 00:28

Thank you. Happy to be here.

Alex 00:29

We’re delighted to welcome back Ken Covinsky, a frequent guest and host on this podcast who’s a professor in the UCSF Division of Geriatrics. Ken, welcome back.

Ken 00:38

Good to be here, Alex.

Alex 00:39

And we’re delighted to welcome Kristie Hsu, who is graduating from our UCSF Geriatrics Fellowship and will soon be working in a short stay rehab at the VA in San Diego. Kristie, welcome to the GeriPal Podcast.

Kristie 00:54

Thanks for having me.

Alex 00:55

And my son Kai is here for a little bit to help me with the guitar. He is a college student at Swarthmore Home for the summer.

Eric 01:02

So we’re going to be talking about geriatric patient aligned care teams. Do they work and who should be getting them? But before we go into that topic, we always start off with a song request. Nicki, I think you have a song request for Alex.

Nicki 01:15

I do. My song request, Alex, is Carolina in My Mind by James Taylor.

Eric 01:21

Why did you pick this song?

Nicki 01:23

Well, it’s a great tribute song to my home state of North Carolina, first and foremost. But also this song really reminds me of longing for home. That’s what this song’s always kind of made me feel. And actually that was a really influential concept in how we chose some of the outcomes for the study we’re going to be discussing later.

Eric 01:45

Wonderful.

Alex 01:46

Here’s a little bit. Love this song. Thank you.

Alex 01:56

(singing)

Eric 02:51

Ken, you had a critical question about that song.

Ken 02:54

Well, I think you answered it, Nicki, but I was wondering, is that North Carolina, South Carolina or both? I guess it depends where James Taylor’s from.

Nicki 03:02

North Carolina.

Ken 03:03

North Carolina.

Nicki 03:04

That’s right.

Eric 03:07

Nicki. I’m going to start off by asking you this question. How did you get interested in this topic of outpatient geriatrics care and GeriPACT teams?

Nicki 03:18

Well, I got interested in the question because it’s what I was doing at the time. I was seeing patients in the outpatient geriatrics clinic at rva. In fact, I was the medical director of that clinic for about five years. I was going into the leadership of my hospital and really pitching them that we needed to grow the clinic and make it bigger. When I did that, they asked me, well, how do you know?

How is this kind of clinic better than other kinds of clinics and what are we going to get out of it, et cetera. I thought I would go to the literature and answer that question and I really couldn’t fully. I said, hold that thought, I’ll be back in seven years with an answer and went out and decided to do a research study to really look into some of these questions.

Eric 04:08

Actually tried to figure out do they work and if they do, kind of how do they work and who should get it. I love that. Before we even dive into this topic, maybe we can just describe what a geriatric Patient Aligned Care team is or a GeriPACTt team is. Can you take that?

Nicki 04:27

I was going to say who should take that one? We could all answer that one, I’m sure. Geriatrics Patient Aligned Care Team in the VA is a special variation of how all primary care is delivered in the VA through patient centered medical halls. So it’s a team based care model. And the Geriatrics Patient Aligned Care team was developed to be specifically for older veterans with complex care needs.

Kristie 04:54

Nicki, I wonder if you could tell us more about the specific aspects of GeriPACT that kind of differentiates it from sort of our standard regular primary care at the va.

Nicki 05:07

Yes, absolutely. The way this is implemented in VA is there are really three key ways that a GeriPACTt is different. One of them is the panel size is a little smaller. Another one is that the providers have special training in geriatrics. And then the third is that there’s additional effort for team members like pharmacists and social workers to participate in the care.

Ken 05:31

Nicki, this is like a really. This question is such a good question, but let me, let me throw a question at you just based on recent experience. It just so happens our primary care director at the San Francisco VA is on maternity leave. Yours truly is now in charge of handling all the requests for geriatric consultation and transfer to the geriatric primary care team.

Nicki 06:01

So.

Alex 06:05

If it’s anything like the way Ken approaches palliative care. They’re all going.

Ken 06:12

Well, we do have. I would like to accept them all, but we have limited capacity. We just don’t have that much primary care capacity in geriatrics. I notice, though, that the consults we get from primary care, it’s never like this patient is doing great, and we think they would just love to be seen by a geriatrician. There’s always something wrong, and they can’t quite articulate what’s wrong, but there’s something that’s not going right with the patient, and they’re becoming more complex, and it’s becoming like, a lot of hard work for the primary care provider.

Sometimes it’s a resident who’s moving on and saying, you know, I’m not sure this is a patient who really should be handled by an incoming resident. Maybe like an attending geriatrician or a geriatrics fellow should get this patient so that, you know. So I’m just sort of like the question about what brings somebody into the clinic. And this is maybe a little bit of a pre question for as we go into your study, because I now that I’m doing this, if you kind of told me you were going to assess the outcomes of patients in my clinic, I would have a little bit of fear because, you know, it’s like, well, wait a second. Is like they’re coming to us because they’re like, they’re not doing that great.

Eric 07:39

They’re pretty sick. Something is going on that triggers that Jerry packed kind of referral.

Ken 07:45

Yeah.

Eric 07:45

Is that usually how it gets into Nicki, like, to these GeriPACT?

Nicki 07:49

I mean, you said it exactly right, Ken. Right. It’s. It’s. There’s all sorts of reasons, and sometimes it is because patient or family knows about geriatrics, wants to get in. Sometimes providers leaving, and they’re kind of getting reassigned to the geriatrics based on age or other things. But other times it’s like a call for help. Right. Like, we need something to go differently for this patient.

So I totally get it. And it was a key thing that we took into consideration when we planned this study, because you can’t just look at geriatrics, primary care, and primary care without doing a lot of careful attention to selecting the right patients. Or you could get an incorrect inference about how that care is delivered. Right.

Eric 08:34

Christa, you’ve been doing this for a year as a geri-fellow working in a GeriPACT, right?

Kristie 08:39

That’s right.

Eric 08:40

Have you admitted new patients during that time?

Kristie 08:43

I have, and I think speaking to what Nicki was saying, there are a variety of reasons why I see patients referred to me. So I did inherit a retiring physician’s patients who had the highest in the va. It’s a can score or kind of some of our highest risk patients with the highest complexity. And a lot kind of like Ken was describing, coming from some of my colleagues, people who I was residents with previously, who were feeling a bit overwhelmed. And honestly, I can also kind of empathize with that feeling of overwhelm as a recent primary care resident when there is sort of that degree of complexity and the lack of training in the 4M’s framework to really approach that complexity in a sort of systematic and comprehensive way.

Eric 09:45

Yeah. And is that the problem that we’re trying to solve here with GeriPACT? Nicki, what is Jerry Pack trying to do?

Nicki 09:52

What GeriPACT’s trying to do is really focus on the fact that for some older patients. And I think that. That some. And who are those that would really especially benefit from this model of care is a big question. But for some older people who have complex, often interacting physical and social challenges, we need a model of care that can really think comprehensively about how to help them maintain their independence and quality of life. So that’s the basics behind this, that it’s gonna require an expanded team, additional time, more resources brought in to really serve this particular group of patients well.

Eric 10:30

And that expanded team. Social worker, pharmacist, and a geriatric specialist. Right, Those are the key team members.

Nicki 10:38

Yeah, you got it, Kristen. I think that’s another place where you do see. Sorry to interrupt you. Where you do see variation across the country, because those are like the key members. But like in our geriatrics geripi clinic at the va, we have a physical therapist and occupational therapist we’ve got integrated in the team.

Eric 10:58

Not just consulting, but integrated in the team.

Nicki 11:00

They’re co located while we’re in clinic, they’re in clinic. So you do see differences. And some GeriPACTs have been built out even beyond that sort of core with the social work and pharmacist. But those are the basics for what VA considers to be a Jerry packed nationwide.

Eric 11:18

Kristie, what does your clinic look like?

Kristie 11:21

I wish I had physical therapy and occupational therapy embedded. To be honest, it is very similar to my colleagues impact teams in terms of the team makeup. And so I did see kind of the VA handbook dream version of GeriPACT does have one dedicated pharmacist and one dedicated social worker. And so that FTE dedicated to the GeriPACT team and ours, you know, we do share with other teams and so it’s not sort of dedicated FTE in that way, although there may be some more nuances there since I only practice there half a day a week. And so of course I wonder if that plays into it.

Eric 12:10

All right, so I got a question. So we’re going to get into the study which is comparing Jerry pack to pact. We’ve defined what Jerry packed is. Kristie alluded to what packed teams are, but I’m still confused. Like what is a pack team and how does it differ than usual care older adults are getting outside of PAC teams? Nicki, do you know that?

Nicki 12:36

Well, I was going to say Ken or Kristie might have to take it because I think my first swing at it did not make it clear for you. That’s probably on me.

Eric 12:43

Well, who’s included in a PACT team?

Nicki 12:46

Well, on a PACT team in va, that’s everybody that’s enrolled in a primary care clinic. That is the model that VA is bought into. If you’re enrolled in primary care va, you’re connected to a PACT team, but.

Eric 13:02

Who actually cares for you in a PACT team.

Nicki 13:04

In a PAC team, your core is going to be your primary care provider and then you’re going to have a nurse, an ma. Those are going to be the kind of the core pieces and you’re going to have access generally to the same kinds of interdisciplinary team members that we’ve been talking about, but usually at much less fte. Right. So one social worker is a sort of quote unquote, regular PACT might cover all of the PACT teams. You know, in a, in a given clinic, whereas in GeriPACT you’re really supposed to sort of have your, your own.

So it’s still team based care. It’s still really meant. That’s a really important part of all of PACT is to be able to engage with the interdisciplinary team when needed. But they have higher patient panels, so they have less time to spend with patients and they have less amounts of effort of these different interdisciplinary team members to be involved in care. What do you guys think? Did I get the key points of that?

Ken 14:04

I think that’s well stated, Nicki. I’m going to guess you can tell me if I’m wrong. Alex. Eric, I am going to. I do that all the time. Eric, I’m going to guess what you are thinking is that one of the core principles of good geriatrics models of care and one of the cores of any geriatric model that works is the interdisciplinary nature. You know, so the concept that you have nurses, physicians, therapists, you know, mental health, all talking together and working together.

So that the PACT team at the VA and the VA system, the concept is similar, but it’s not applied just to geriatrics. It’s applied to all primary care. So part of the input of the PAC team is that you actually have a dedicated team that includes a nurse and a social worker, all who are integrated and presumably all know the patients together. So, and I. And I’m guessing what you were thinking, Eric, is that, well, is the PAC team already doing some elements of geriatric care that don’t exist outside the va?

Eric 15:07

Yeah. And what does it look like outside? Like, Kristie, you were a chief resident at ucsf. You were a primary care resident. What did primary care look like to you during your training outside of the VA system?

Kristie 15:21

Yes, I did practice outside of the VA system. And I will say, in general, kind of the feeling amongst even primary care residents is a bit of jealousy of our colleagues practicing in a VA PAC team or a regular VA primary care because of the abundance of resources. When it came to having a pharmacist, I did not have a pharmacist in my primary care clinic. Having social work at kind of panel size that was quite different from what our social worker was juggling in our primary care clinic and then kind of the ability to refer to our mental health services. Just as Nicki was saying, there is a lot of sort of social and psychosocial complexity when it comes to our patients, and we didn’t have sort of that robust mental health in that way.

Ken 16:18

And actually, can I take what you were both driving at? You can edit this out if you don’t want, but I’m going to make a little advertisement here. Let’s put this on the table. VA care is better than community care. That primary care delivered in the Department of Veterans affairs is already better than the standard that exists in the community. Like multiple studies show that. And it’s for reasons like this. There’s more availability for services, care is better aligned. So let’s just. I mean, just people need to know that VA deli, VA is not perfect, but VA delivers much better primary care than exists in the community.

Eric 16:58

Great point, Ken. And let’s talk about that. So this is a study, right, Nicki? So you did a study not comparing kind of general usual care for older adults to. To jerry pack. You’re looking at these VA packs versus jerry packs. Yes, the jerry pack sounds like you have some more kind of. It’s more resource intensive. Right? You have a Social worker, pharmacist. You have a geriatric specialist, geriatrician on board. They have smaller panel sizes. So when you went to your boss, your boss is probably thinking, why should I give Nicki all this stuff? Like this is really expensive. Does it do anything? And you sought out to answer that question, is it better?

Nicki 17:38

Yep, you got it.

Eric 17:40

What did you do in this study to figure that out?

Nicki 17:43

Well, the first thing I did was I went and found some other good researchers to get together with me to help tackle this. Because this is a tough question, right? We were not talking about doing a randomized clinical trial where we could control where people go. We were talking about trying to do a nationwide evaluation to figure out the average effect of this model. There were many, many pitfalls that we could have stepped into that would have really, as Ken was alluding to earlier, led us down the wrong path. We used a lot of methods that people sometimes refer to as target trial emulation methods.

Basically try to think really carefully about how we could make sure we were comparing apples and apples when we looked at these two patient groups. So the very short summary of what we did is we found GeriPACTS that were roughly similar across the country, about 57 of them. We recruited patients who were having care in the, in the GeriPACT setting and then we matched them with people who were still receiving care in traditional pact on a list of characteristics. And then that’s the two groups that we compared. The list of characteristics that we matched on was based on what you were talking about earlier, what drives people into gerripact? So what are the factors associated with going in? Because that’s what we really needed to control for to make those reasonable comparison groups.

Eric 19:17

One thing that is always incredibly hard in any EHR data and I think is probably a component of what drives people in is functional status and not the number of diseases, but the course, the decline, which I feel like functional status is probably a pretty good marker of the diseases are getting worse. Were you able to include functional status in your matching?

Nicki 19:47

We did. We included a measure that gets at functional status. It’s not really account of ADLs or IDLs. We use the GEN Frailty index. So it’s a claims based index, but it’s been validated against functional status. So the things that we matched on were like demographics and this comorbidity score that Kristie mentioned earlier, whether you’ve been in the hospital, because Ken mentioned that sometimes that’s what’s driving people to come in. And then this other measure of Frailty with score called for lt. But essentially it has been shown to predict functional ability. Those are the things that we matched up.

Alex 20:23

I can tell Ken is struggling.

Eric 20:25

Ken is jumping out.

Nicki 20:28

Is this where we’re going to say propensity score,

Nicki 20:34

distance function match, at least.

Eric 20:36

I don’t think we’re going to be talking about regression of mean, which is another favorite topic of Ken.

Ken 20:40

I don’t play poker because I lose a lot of money.

Ken 20:47

So.

Nicki 20:47

Yeah.

Ken 20:48

So, Nicki, like, what? This was like an exquisitely well done study. I mean, it’s like, it was like, you know, I learned about methods reading your study, and I even read your supplements because, like, I think if I do something like this, how am I going to do it? And like, if I was writing a grant, like, using like, observational methods, I’d say we’re going to use state of the art methods as described by Hastings. So it was really just beautifully done because it’s challenging because you’re trying to. It’s not randomized and you’re trying to equalize these groups as much as possible. And I think you did everything you could have done to control for what you could control for, and now the question is about what you can’t control for.

Nicki 21:36

You got it. You said it. I mean, first of all, being invited to participate in this conversation meant some people read my study. So already that was like the hallelujah chorus, right? And now you just said you read the supplement. So.

Kristie 21:49

Okay, Nicki, we nerded out on your study.

Alex 21:53

Kristie led the Journal Club in our division of geriatrics, and we nerded out about it. She was a great Journal Club.

Nicki 21:59

It’s incredible. Like, you know, I worked really closely with Courtney Van Houten, who’s a health economist, and Valerie Smith, who’s a biostatistician. These are brilliant scientists. And it took all three of our brains working together hard for a long time to come up with these methods. So thank you for the compliments. We did the best we could. And where Ken is also driving is, it’s still not perfect. Right? You could definitely still think of other things that we could have included in the models. And no observational study at the end can say we took care of all selection bias. It’s all gone. That’s just.

Alex 22:38

What are you most worried about, Ken?

Ken 22:39

Well, let me take it back to the initial discussion about how people get in and think, like, let’s one minute about what happens when somebody is seen for the first time in a geriatric clinic or a consult clinic. And Kristie you weigh in, because I’d be interested in what you do.

Alex 22:57

But.

Ken 22:58

So the central problem, the reason for referral, is patient not doing well. We can’t really describe why. So the first part of our assessment is actually to disarticulate not doing well and the why of that. So that actually involves, like, the tools and training of geriatrics. We do what’s known as geriatric assessment. And it’s a really critical look at the patient’s physical, cognitive, mental health and psychosocial functioning. And that identifies a lot of problems. So that part of the art of geriatrics care actually is putting a name or a condition to the reason somebody is not doing well.

So why does that matter? In a study like this, you can’t control for what you can’t measure. So we actually are now naming all the stuff that explained why the patient wasn’t doing well. And because it wasn’t named before, it could not have been included in the electronic record database. So it’s sort of, to me, one of the fallacies of all of this artificial intelligence machine learning is like, you know, there’s no algorithms that could deal with a measure that’s not there.

Ken 24:19

So I think that’s sort of like. So I think one of the fundamental questions here is like, how, you know, is that picked up by other stuff that you were able to measure and how important are all those stuff?

Nicki 24:32

Yeah, I think it’s such a great point. Like, in our study, what we did is we really, we looked at people who were in the VA and we’re seeing PACT providers, and then they transferred over to GeriPACT. So then we looked at the first sort of 18 months that they were in a GeriPACT. We designed it that way so that we could get our matching variables from the time point when they had not been exposed to GeriPACT. So presumably they were equally likely or unlikely to have had those conditions sort of named if they were present but not yet diagnosed. But that definitely also created another challenge in the study, which was we were able to look at the first 18 months they were in GeriPACT. I would love for somebody to tell me how long it takes primary care to change the true trajectory of health.

Eric 25:24

I got a question then.

Nicki 25:25

Right. But I think it’s like, we don’t know.

Eric 25:28

Going on top of kin. I love this design. This is what you’re talking about, like target trial. Everybody’s kind of getting the same thing, and then they get the intervention just like in a randomized control trial. So going to Kens, if you look at that. And then all of a sudden, the GeriPACT team has a bunch more geriatric syndromes. Is it that geriatric care teams don’t work, or is it that we’re just picking up all those syndromes? So how did you think about what is the right process, primary outcome you want to look at, given that they’re probably going to get more assessments and maybe even more diagnoses?

Nicki 26:02

Yeah, I mean, it’s a great question. So what we wanted to do is we wanted to look at two things. We wanted to look at just what you’re talking about, assessments, the process of care. And so we looked at were they getting screened for functional status? Were they getting screened for other geriatric syndromes, incontinence, falls, et cetera? Were they having advanced directives, conversations? Then for the outcomes part, we wanted to know some experience of care measures from the patients.

We want to know some patient reported outcomes for health and well being. But we also wanted to look at what we called home time as our primary outcome. Now we get to think back to Kai and Alex’s beautiful rendition of Caroline. My mind this is because in all my years of practicing geriatrics, the number of times that I’ve heard patients express to me that what they really valued was going home or staying home or being home. It’s just been a really consistent theme.

It’s not always, but we hear it a lot. What we were trying to do in the study was to create an outcome that would assess that. How well did being in Jerry packed help patients meet the goal of being at home more? So we looked at this home time as the primary outcome.

Eric 27:26

What consisted of non home time is this like hospitalizations, dialysis days? Just what was that concept we talked about, Alex, in another podcast, the Healthcare Footprint. Like the amount of time that they’re just seeing?

Nicki 27:42

Well, you know, we picked home time and we thought, well, that’s a nice, easy conceptual measure. Of course. No, it’s deeply complicated. Exactly as you said. What we ultimately landed on was using home time was days that you were not in the hospital, not in the skilled nursing facility, not in a rehabilitation clinic, not an emergency department. Okay, we’ve got lot.

We actually are doing lots of research now and doing some focus groups. Again, this is led by Courtney Van Halven, asking patients what should be in a home time measure. Because I think there’s a lot more to figure out there. You said it. With dialysis, outpatient surgery, there’s a lot of other stuff you could consider. But what we did was just those four that I knew.

Eric 28:25

Yeah, I remember I brought this up on another podcast, but Ken, during our literature updates, he talked about another study. Just looking at just the footprint that we have in medicine, the time that we ask older adults just to come for our lab tests, our outpatient visits. And it’s like amazing the number of days per year that is just allocated towards us. Is that a good summary, Ken?

Ken 28:51

Yeah, yeah. No, I mean, it was a substantial number. I can’t remember. There was over like 10% of patients spend more than one day a week with us, you know, over the course of a year or so.

Eric 29:02

Yeah, that’s not home time. That. I would not put that as home time. Right. That is, we are asking them to be away, but that wasn’t here. So you’re looking at hospitalizations. Eds, does geriatric Patient Aligned Care teams, do they work based on that outcome?

Nicki 29:18

To that question, I’m going to tell you what we found when we looked at that outcome. What we found is that for patients who had been exposed to GeriPACT for 18 months, they had no difference in the, in their home time compared to people who stayed in traditional packs. So there was no difference. Now, the reason I laughed and said, I’m not going to answer your question is because we didn’t really go into this to sort of ask this big existential question of like, you know, is geriatrics valuable or not valuable or anything like that like it is.

That’s not a question we’re poking at today. It really is, how do they work and what could they potentially. So for the outcomes we measured, we found no difference in home time. We did see a significant difference in the assessments, the assessments for falls and the other things that we mentioned earlier. So we definitely could see that care was delivered differently, but we could not observe that the outcomes were measurably different after this 18 months of exposure. Hmm.

Kristie 30:25

I am very interested in. I think you stated it so well. And I am wrestling as a trainee with practicing in GeriPACT. I have been trained to do the screenings, do the functional assessments, think about the falls, think about incontinence, and it’s amazing to see that that is borne out and that training works. I wonder if you could speak more to the discrepancy with the outcome measures and kind of what you think is driving the outcomes that you saw with the data.

Nicki 31:03

Sure. Well, I mean, you know, as a scientist and not a geriatrics evangelist, which I could be reasonably described as both on different days of the week, but you would have to say that one possible explanation is that GeriPACT did not work right. Or that did not have the intended effect, and that’s why we didn’t see the outcomes change. I’m more of the opinion that it could be an issue with time horizon. So if you think about assessments, then what ultimately happens as a result of doing these assessments that you just mentioned that we’re trained to do is it depends on the positivity rate, the actions that are taken in response to what you find.

And then, you know, it takes some, again, downstream time to sort of realize the effects of those interventions. So in our study, the people who were in GeriPACT for 18 months had about six visits total, so about six visits to have the assessment come back and maybe review the results of the assessment and then take some steps to intervene. And I think we just don’t know if there might be some downstream effects that we weren’t able to observe given the study timeframe. So that’s something for us to look into in the future. I think another thing for us to look into the future is what are other potential effects that our patients care about?

One of our geriatrics fellows, Chelsea Perfect, is joining our faculty soon, very happy to say, did another study where she looked at recognition of cognitive impairment. Same population, and she looked, and people who were exposed to GeriPACT were more likely to have a diagnosis of cognitive impairment or dementia. This is exactly what Ken was articulating when we were talking about the challenge of the study design. There could be downstream positive effects of that as well.

Alex 33:10

So to paraphrase Nicki, you suspect that if you could have looked out 10 years, which is like a really long time, granted, for like a study, the longest NIH study is usually five years. And some of that’s got to be analysis. So it’s really usually like a three year at most window. But if you could have gone out much further, then you suspect you would have seen differences. Even with the limitations of this study design.

Nicki 33:37

I think it’s possible. I think if NIH or VA would like to give me the money to do that, my door is open, and I hope that they will. I think we need to study it and answer the question. I think it’s possible.

Eric 33:49

How much do you think an observational study, even the best observational study, can really answer the question? Because this causality question, like, does Jerry pack improve this versus, like, we’re always going to be mired in this issue of. Well, the people who go into Jerry packing are inherently different than those who don’t like there is the same thing we see in these observational palliative care studies.

The reason they’re getting a palliative care consult is something’s happening. So unless you do a randomized control trial, you can’t answer that question. But we can answer other questions like, what are these components that are happening during these jerry packed interventions? What are we seeing with them? Maybe posing additional hypotheses. Thoughts?

Nicki 34:41

Well, as people have tried to study these questions with randomized controlled trials, and that’s not so perfect either because patients don’t always want to adhere to the randomization assignment of who their doctor is. Right. So people have tried to say randomize you to change clinics or stay, and people crossed over like mad because people like to kind of control that decision.

Right. So I think there are challenges no matter what the study design is. But I think that from my perspective, if we’re using the best observational methods that we have available so that we’re controlling bias to the best of our opinion, we’re still learning something and moving the field forward with these observational studies. I don’t think it’s a throw the baby out with a bathwater situation, but I’m watching Ken’s face now that I know he to see if he’s going to agree with me or not.

Alex 35:36

Looks like my puppy being ready that.

Eric 35:38

Wants to get outside.

Nicki 35:42

I’m so glad we’ve got video on this topic.

Ken 35:46

I don’t think I’ll comment on that observation.

Ken 35:52

Yeah, no, I agree with you, Nicki, and I think a few. I actually do wonder if the time is right for an RCT though. You’re right. It’s like, it’s hard, but it’s hard. It would take a lot of resources.

Eric 36:08

Well, our last podcast last week, so you can go, all of our listeners can go to it. We just published one on comprehensive dementia care. Two huge randomized controlled trials of comprehensive dementia care, one with the additional layer of palliative care, both negative on their primary outcomes with some interesting secondary outcomes that were positive. And even in that running mass control trial, like you’re trying to think, oh, you know, maybe we should be looking at these secondary outcomes as the importance. And like, what other. Like, I understand that RCTs are not end all be all. Yeah, Ken, you were going to say more.

Ken 36:45

No, I mean, I think like if they had given you unlimited resources, Nicki, to do this as an observational study, so for example, that I think it’s possible one might have had a different answer if you actually could have done a geriatric assessment in both groups and actually put all the stuff that we said you couldn’t measure, you actually could have adjusted for that. I think the other thing I wonder too is that the outcome you measured is certainly important. And I think it’s the kind of outcome we often take to the people who pay for health care.

Because I mean, obviously one of the motivations of this is if we could tell like the VA that oh, you’re going to save money on emergency room use or hospitalizations, like the clinic will pay for itself. Of course, we do a lot of things in health care. I sometimes object that geriatrics and palliative medicine, why do our interventions have to pay for itself if they do good for patients? The cardiologists never have to make that argument. So that said, I’m also wondering, a lot of the things that might happen that are good in a GeriPACT are things that were difficult to measure so that lifespace mobility, for example, so if they got the right therapy, we helped them get the mobility equipment they needed.

They actually could use their bathrooms and showers because we thought about putting pudding and grab bars. So that there’s a lot of aspects of quality of life that I wonder were better or like caregiver burden or caregiver stress. So that there’s a lot of other outcomes that I think maybe aren’t cost outcomes, but would have impacted quality of life. And those, of course, would have taken a lot of resources to measure.

Nicki 38:36

Yeah, and I think another really important point is sort of back to the beginning of the conversation. We have to remember the context in which we did the study which was in the va. So if we had compared this model outside of the VA and the comparison group did not have the things we talked about earlier of PAC teams, team based care, access to the interdisciplinary teams, we might have gotten a different result.

And in fact, some of the studies that have done comparisons of, I’ll say, intensive primary care models that have shown bigger effects than we observed here have done them in, for lack of a better word, fee for service model where there wasn’t team based care and they served greater effect. So we were comparing against a pretty high bar in terms of quality of primary care that was already in place.

Eric 39:30

Kristi, I want to give time for you to ask any questions that you have.

Kristie 39:35

Yeah, I think that again, I just learned so much from the methods and just so appreciate, Nicki, you taking the time to join us today. I guess a bigger picture question I have is knowing that there is a limited supply of geriatrics trained providers did looking at this data and thinking about this and presenting it to others, kind of what are your takeaways in terms of the best use of geriatrics trained providers and outpatient care? And this is open to anybody too, if you have other reflections on that question.

Nicki 40:12

Probably all have opinions on this, but now I’m getting into the can jump, jump mode. I really consider geriatrics a precious resource. Limited, limited precious resource. Right. What are there 7,500 geriatricians in the country right now? And that number is probably only going down. So I think it’s stable.

Eric 40:34

It’s stable. The latest data from AGS, it has been stable for the last 10 years.

Nicki 40:40

But I like the optimism and believe me, I’m doing everything I can to train more geriatricians and thank God for Christine. All the things I do think it’s a really valid question. And I think that to me, what the data made me double down on is geriatrics expertise. We know how to deliver really good care and so we should be involved in leadership and geriatricians should be involved in designing care models for older adults. For sure. In terms of the delivery like which older adults really need a geriatrician in the clinic every time they come to the clinic? I think that’s a question we have to keep pursuing.

Eric 41:22

And then there’s those key components, even those key components that we see with pact. So interprofessional care, there is a big focus on things like advanced care planning, but maybe including some of those other aspects for that primary geriatrics care delivered by anybody seems important.

Alex 41:40

Ken, how would you answer Kristie’s question?

Ken 41:43

Yeah, no, I think it is really one of the question of geriatrics is how do we spend our time to best advance patient care and is it best spend on an individual level or system planning level and is it guided towards those most in need or who are most vulnerable? I am not sure I have the answer to that because I think some of it is. We also have to teach people how to provide better geriatrics care and teach primary care providers.

I tend to think that, like I agree with you Nicki, that I think a lot of it has to be on the health system leadership level and getting these aspects of quality that are better in geriatrics moved into more primary care models. So that I know we’re discussing a study where the outcome for the primary outcome was negative. Nonetheless, I still believe that providing geriatric primary care for those who are most vulnerable and most needy Makes a difference.

Eric 42:53

Nicki, what’s next for you?

Nicki 42:55

Well, in terms of research, this is probably not what you meant, but where my mind is going is I’m now the Chief of General Medicine at Duke, which means I get to think about how to integrate geriatrics into primary care in a whole different way. That’s really exciting for me, and it’s made me think about the results of these studies in a whole different way.

But really, the research questions we want to dig into are exactly the ones that Ken was talking about. Who benefits the most from geriatrics primary care model so that we better deploy this precious resource for people who stand to benefit. That’s a $64,000 question, but we’re going to keep pushing towards it.

Eric 43:36

Well, I want to thank all of you for being on this podcast, but before we end, I think Alex got a little bit more. A little bit more Kai with you. Okay?

Alex 44:25

(singing)

Eric 44:50

Nicki, Kristie, Ken, thanks for joining us on this podcast.

Nicki 44:54

Come visit me in North Carolina.

Eric 44:56

All right, and thank you to all of our listeners for your continued support.

***** Claim your CME credit for this episode! *****

Claim your CME credit for EP372 “Is Geriatrics-focused Primary Care (GeriPACT) Better?”
https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=16280

Note:
If you have not already registered for the annual CME subscription (cost is $100 for a year’s worth of CME podcasts), you can register here https://cme-reg.configio.com/pd/3315?code=6PhHcL752r

For more info on the CME credit, go to https://geripal.org/cme/

Disclosures:
Moderators Drs. Widera and Smith have no relationships to disclose.  Guest Eric Wong and Thiago Silva have no relationships to disclose.

Accreditation
In support of improving patient care, UCSF Office of CME is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Designation
University of California, San Francisco, designates this enduring material for a maximum of 0.75 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

MOC
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 MOC points per podcast in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

ABIM MOC credit will be offered to subscribers in November, 2025.  Subscribers will claim MOC credit by completing an evaluation with self-reflection questions. For any MOC questions, please email moc@ucsf.edu.