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Preventive Healthcare for Older Adults. Framing the Issue. USPSTF charge. Conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications)

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Presentation Transcript
uspstf charge
USPSTF charge
  • Conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications)
  • Develops recommendations for primary care clinicians and health systems.
  • Usual Model: Folic Acid Supplementation in Pregnancy
    • Single population
      • Women of Childbearing Age
    • Single intervention
      • Folic Acid supplementation
    • Single outcome
      • Neural Tube Defects
challenges in applying model to the very old
Challenges in Applying Model to the Very Old
  • Many geriatric disorders have multiple risk factors, interventions, and expected outcomes;
  • Older adults are not often represented in clinical trials and are more heterogenous than younger adults; and
  • Important outcomes may not be measured and reported in ways conducive to evidence synthesis and interpretation.
falls analytic framework

Intervention*

(alone or in combination)

Multifactorial Assessment and Management

Risk Evaluation of ages 65+ years

Fall-related fractures and serious injuries;

Quality of Life;

Mortality;

Disability

Single clinical treatment

(with or without screening)

Falls

High-risk

subpopulation

4

2,2a

Clinical Education/

Behavioral Counseling

3

Home Hazard

Modification

2b

Adverse effects of interventions

Exercise/

Physical Therapy

Other positive outcomes of interventions

Falls Analytic Framework

1,1a

challenges nontraditional outcomes
Challenges: Nontraditional Outcomes
  • Years of Life gained may not be as important as
    • Independent life or maintenance of function
    • Quality of life, etc
  • Caregiver outcomes
    • Ability to plan by knowing that a patient is dementing
  • Timing of outcomes
    • For syndromes, often can’t reverse the underlying progression of disease (frailty, dementia) but can improve for a period of time
      • How short a period of time is clinically significant
      • Can outcomes be measured too far out and miss significant short term gains?
        • Eg, Hospitalizations at 24 months after a fall intervention?
  • When to stop screening?
payment challenge uncovered preventive services
Payment Challenge: Uncovered Preventive Services
  • Medicare will now pay for USPSTF Grade A and B recommendations (MIPPA)
  • BUT many preventive services have strong evidence showing their benefit, but are not paid for by Medicare
    • are unlikely to be able to meet the stringent criteria for USPSTF recommendation- that SCREENING will improve outcomes more than waiting for the disorder to be manifest
      • Glasses
      • Hearing Aids
      • Dentures
    • What needs to be done to obtain coverage for these preventive services?
slide8
Elizabeth Eckstrom: Synthesizing the Evidence
  • Marcel Salive: Medicare coverage of Preventive Services