Papers by Barbara Rapport
Patient-Centered Paradigm for Managing Autonomic Long COVID Symptoms During Sports and Exercise
Clinical Journal of Sport Medicine
Using Multisite Process Mapping to Aid Care Improvement: An Examination of Inpatient Suicide-Screening Procedures
Journal for Healthcare Quality, 2019
Although most suicides occur outside of medical settings, a critical and often overlooked subgrou... more Although most suicides occur outside of medical settings, a critical and often overlooked subgroup of patients attempt and complete suicide within general medical and inpatient units. The purpose of this quality improvement initiative was to perform a baseline assessment of the current practices for suicide prevention within medical inpatient units across eight Veterans Affairs medical centers throughout the nation, as part of the VA Quality Scholars (VAQS) fellowship training program. In conjunction with the VAQS national curriculum, the authors and their colleagues used multisite process mapping and developed a heuristic process to identify best practices and improvement recommendations with the hopes of advancing knowledge related to a key organizational priority—suicide prevention. Findings demonstrate a multitude of benefits arising from this process, both in relation to system-level policy change as well as site-based clinical care. This interprofessional and multisite approac...
Deprescribing Medications for Chronic Diseases Management in Primary Care Settings: A Systematic Review of Randomized Controlled Trials
Journal of the American Medical Directors Association, 2018
Perform a systematic review to evaluate the outcome of deprescription compared with standard care... more Perform a systematic review to evaluate the outcome of deprescription compared with standard care. The focus was on chronic medical and mental health conditions managed in primary care. The databases searched include PubMed, Medline, EMBASE, the Cochrane Library, Scopus, and Web of Science. Each study was assessed for bias with the Cochrane Collaboration tool. This review included outpatient, assisted living, nursing home, and acute care settings (if medications for chronic disease were deprescribed). Subjects were non-terminally ill adults 18Â years and older. Primary outcome was successful deprescription, defined as a statistically significant reduction in medication burden between the intervention group and the standard care or control group, or when more than 50% of intervention subjects were able to tolerate medication discontinuation compared with control by the end of the study. Fifty-eight articles met the study criteria. Thirty-three (58%) had a high risk of bias. Studies va...
Journal of Pain and Symptom Management, 2017
Hyperglycemia and Hypoglycemia in Patients with Diabetes in Skilled Nursing Facilities
Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, Jan 3, 2017
Endocrinologists are faced with a growing elderly patient population with diabetes (DM), some of ... more Endocrinologists are faced with a growing elderly patient population with diabetes (DM), some of whom are in skilled nursing facilities (SNF). Efforts at managing their DM is hampered by concerns for hypoglycemia. This study aimed to determine the frequency of hypo- and hyperglycemia in SNFs, and associated factors. We reviewed medical records of 200 consecutive residents admitted to 2 SNFs in the Cleveland area in 2014 with documented DM, aged ≥ 65 years. Data collected included blood glucose (BG) levels and DM regimens. Frequency of hyper- and hypoglycemic events was noted. Since patients had different frequencies of BG checks, event-days were calculated. Mean age, BG and HbA1c ± SD were as follows: 80.2 ± 8.2 yr, 172.4 ± 40.3mg/dL and 7.5 ± 1.9%. Seventy-one % were on insulin alone, 15.5 % on insulin and oral diabetes agents, and 13.5 % on oral diabetes agent on admission. Patients with at least one event were as follows: 38% hypoglycemia, 3.5% severe hypoglycemia, 90.5% hypergly...
Cleveland Clinic journal of medicine, 2015
Journal of the American Medical Directors Association, 2015
This is the 11th annual Clinical Update from the AMDA meeting article. This year the topics cover... more This is the 11th annual Clinical Update from the AMDA meeting article. This year the topics covered are hypertension after the Systolic Blood Pressure Intervention Trial; chronic obstructive pulmonary disease risk factors, diagnosis and management including end-of-life planning, and the difficulties with exacerbations such as breathlessness; diagnosis and treatment of cognitive impairment and dementia; and wound care and pressure ulcer management. Ó 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine. Hypertension guidelines do not reflect the heterogeneity of the older population. A robust 80-year-old woman living in the community may play tennis and cycle daily, and have a life expectancy of more than 12 years. 1 Another 80-year-old woman in the lowest quartile of fitness may require substantial care and have a life expectancy less than 5 years. The 2017 guideline published by the American College of Physicians and American Association of Family Physicians 2 recommends a target systolic blood pressure (sBP) of 150 mm Hg, or 140 mm Hg if there is a history of a cerebrovascular event, in adults 60 years and over. There is no separate recommendation for frail elders, or specific recommendations for elders 80 years and over, regardless of frailty. Recommendations for adults 60 years and over by 8th Joint National Commission 3 and Canadian Education Hypertension Program 4 are similar. The European Europe 5 and the Veterans Administration/Department of Defense 6 guidelines offer statements of caution for the oldest and/or frailest individuals. Clarity regarding heterogeneity of the older population may soon be possible, since design of the recently published Systolic Blood Pressure Intervention Trial (SPRINT), 7 incorporates at least some of the heterogeneity of the older adult population. Current hypertension guidelines are driven by the major studies published over the past 3 decades preceding SPRINT. The large double-blind placebo-controlled legacy trials enrolled older adults with stage 2 hypertension (sBP >160 mm Hg) and targeted a systolic
Cleveland Clinic journal of medicine, 2015
This paper discusses recent developments and recommendations for elderly patients concerning immu... more This paper discusses recent developments and recommendations for elderly patients concerning immunizations, heart failure, lipid therapy, blood pressure control, and dementia.
Effect of a Novel Interdisciplinary Teaching Program in the Care-continuum on Medical Student Knowledge and Self-Efficacy
Journal of the American Medical Directors Association, 2015
Medical students report that they receive inadequate training in different levels of care, includ... more Medical students report that they receive inadequate training in different levels of care, including care transitions to and from post-acute (PA) and long-term care (LTC). The authors implemented the Medical Students as Teachers in Extended Care (MedTEC) program as an educational innovation at the Cleveland Clinic to address training in the care-continuum, as well as the new medical student and physician competencies in PA/LTC. MedTEC is a 7-hour interactive program that supplements standard geriatric didactics during the medical student primary care rotation. This study evaluated the performance of the program in improving medical student knowledge and attitudes on levels and transitions of care. The program occurs in a community facility that includes subacute/skilled nursing, assisted living, and nursing home care. Five to 8 students completing their primary care rotation at the Cleveland Clinic are required to participate in the MedTEC program each month. The program includes up to 3Â hours of interactive discussion and opportunities to meet facility staff, residents, and patients. The highlight of the program is a student-led in-service for facility staff. With institutional review board approval as an exempt educational research project, pre- and postactivity surveys assessed self-efficacy and knowledge regarding levels of care for students who participated in the program and a student comparison group. The post-program knowledge test also was administered to hospital medicine staff, and test performance was compared with medical students who participated in the MedTEC program. Between October 2011 and December 2013, approximately 100 students participated in 20 sessions of MedTEC. All students reported improved self-efficacy and attitudes regarding care of older adults and care transition management. Mean percentage correct on the knowledge test increased significantly from 59.8% to 71.2% (PÂ =Â .004) for the MedTEC participants but not for the comparison group students (63.1%-58.3%, PÂ =Â .47). There was no significant difference in mean percentage correct on the post-program knowledge test between MedTEC medical students and hospitalists (71.0% versus 70.3%, PÂ =Â .86). Students led 8 in-service sessions for facility staff on various topics relating to the care of older adults in PA/LTC. The MedTEC program appears to be a successful innovation in medical student education on levels of care. It could serve as a model for building competency of health professionals on managing care transitions and determining appropriate levels of care for older adults.
Cleveland Clinic journal of medicine, 2010
Clinical trials in the past few years have yielded findings that are relevant for clinical practi... more Clinical trials in the past few years have yielded findings that are relevant for clinical practice, not just for geriatricians but for all physicians who have elderly patients.
Disparities in long-term healthcare
The Nursing clinics of North America, 2009
Health disparities exist in long-term care as well as in the community. Disparities in healthcare... more Health disparities exist in long-term care as well as in the community. Disparities in healthcare typically result from the interplay of insurance; healthcare access; health literacy and cultural disparities; and geographic distribution. Residence in the nursing home complicates the situation since it introduces facility differences, regulations, and payer issues. This article offers two vignettes of residents that illustrate management of chronic issues, and addressing end of life concerns.
Breast surgery: minimally invasive diagnosis and treatment
Clinics in geriatric medicine, 2006
The increasingly large proportion of elderly women in the United States population carries a disp... more The increasingly large proportion of elderly women in the United States population carries a disproportionate burden of breast cancer. The advent of minimally invasive surgical techniques applicable to breast disease has brought new opportunities to diagnose and treat breast cancer in the older population. This article reviews issues important to the evolving field of breast cancer management in older women: cancer risk and screening considerations, diagnosis and biopsy approaches, and surgical treatment options based on current studies and recommendations.
Prevention for the older woman. A practical guide to managing cardiovascular disease
Geriatrics, 2002
American women are more likely to die from cardiovascular disease than from any other cause. Alth... more American women are more likely to die from cardiovascular disease than from any other cause. Although hypertension is most prevalent, most deaths are attributed to coronary heart disease. Heart disease in women manifests approximately 12 to 15 years later than in men, up until menopause. Then the severity of coronary artery lesions in women accelerates until it equals or surpasses that of men by the late 70s or early 80s. Physicians can help older women reduce their risk for heart disease and stroke by managing hypertension and hypercholesterolemia and providing beta-blocker treatment when indicated after MI. Nonpharmacologic interventions may be effective as well. New guidelines for aspirin help identify women under age 80 who would benefit most from antiplatelet therapy.
Cleveland Clinic journal of medicine, 2009
Behavioral problems are common in dementia and may reduce the quality of life of the patient and ... more Behavioral problems are common in dementia and may reduce the quality of life of the patient and disrupt the home life of family members. Families want a pill that can cure the myriad phenotypes of a decaying brain; unfortunately, there is no pharmaceutical silver bullet. This paper reviews the evidence for using different classes of drugs for the behavior symptoms commonly encountered in dementia, focusing on concerns that the primary care physician would have about using these drugs.
Journal of the American Medical Directors Association, 2014
The American Medical Directors Association, referred to as AMDAe Dedicated to Long-Term Care Medi... more The American Medical Directors Association, referred to as AMDAe Dedicated to Long-Term Care Medicine, changed its name in 2014 to AMDAeThe Society for Post-Acute and Long-Term Care Medicine. With the growing recognition that post-acute care medicine requires a dedicated clinical skill set and research effort into healthcare outcomes, it may be appropriate for JAMDA to reflect these differences as well. About 20% of hospitalized Medicare Beneficiaries were discharged to subacute units and skilled nursing facilities (referred to collectively as SNFs) for post-acute care (PAC) in 2011 1 because of either complicated nursing needs or functional decline during hospitalization. 2 This percentage may have been driven by implementation of the hospital inpatient prospective payment system, reducing the length of hospital stay and exponentially increasing the use of postacute care facilities. Medicare SNF costs in 2000 were $12 billion, and by 2011 had risen to $31.3 billion. Despite the burgeoning number of older adults receiving PAC in SNFs, these settings have not received the attention to their healthcare outcomes that hospitals have received in the past decade or more. Patients discharged from the hospital to SNFs have a higher mortality rate than those discharged to home. For example, when discharged to SNFs with a diagnosis of heart failure, patients had a 53.5% 1-year mortality rate compared with 29.1% for patients discharged to home (P < .0001). 7 Although a portion of the adverse outcome is driven by the advanced average age of patients and the burden of comorbidity, there is likely substantial opportunity to improve facility care. In 2014, the Office of Inspector General (OIG) reported that 33% of Medicare beneficiaries in SNFs experienced adverse events, and physician reviewers determined that 59% of these events were clearly or likely preventable. 8 These findings are comparable to (and perhaps slightly worse than) hospital adverse event rates. In 2010, the OIG found that 27% of hospitalized Medicare beneficiaries experienced adverse and temporary harm events, with nearly one-half of the events being preventable. The OIG reported that about one-third of identified events in SNFs were medication related, often causing delirium. Infections including catheterassociated urinary tract infection, Clostridium difficile, aspiration pneumonia, and surgical wound infections constituted about a quarter of events. The remainder of identified issues involved falls, electrolyte disturbances resulting in acute kidney injury, pulmonary embolus, and other care incidents. Addressing the adverse events and poor outcomes of SNF postacute care requires attention to many factors, including regulatory issues, quality measures, practitioner staffing models, and best clinical practices.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, 2006
Health care professionals suffer from information overload and struggle to filter evidence releva... more Health care professionals suffer from information overload and struggle to filter evidence relevant to their field. There is a need for solution that facilitates filtering and delivery of information specifically tailored to the needs of researchers and practitioners, and provides an opportunity to efficiently critique and share evidence- based articles. Our "online evidence- based information portal" can serve as a model for knowledge delivery, sharing, management and archiving that can be applied to any biomedical domain.
Clinical Update on Nursing Home Medicine: 2014
Journal of the American Medical Directors Association, 2014
This is the eighth yearly update on clinical care in the nursing home. Topics covered this year a... more This is the eighth yearly update on clinical care in the nursing home. Topics covered this year are heart failure, delirium, nutrition, hospice, diabetes mellitus, frailty, and sarcopenia.
Falls in the Nursing Home: A Collaborative Approach
Nursing Clinics of North America, 2009
Problem solving using a collaborative approach may reduce the risk of falls in the nursing home. ... more Problem solving using a collaborative approach may reduce the risk of falls in the nursing home. Interventions need to be tailored to the individual&amp;amp;amp;amp;amp;amp;amp;amp;#39;s cognitive and physical impairments as well as be feasible in the particular long-term care setting. Polypharmacy, Vitamin D deficiency, delirium, and urinary incontinence are among several risks for falls that are discussed in this article.
Traffic Injury Prevention, 2008
Clinical Update on Nursing Home Medicine: 2010
Journal of the American Medical Directors Association, 2010
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Papers by Barbara Rapport