1. Preventive Healthcare for Older Adults Framing the Issue

2. 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 Single population Women of Childbearing AgeWomen of Childbearing Age Single intervention Single intervention Folic Acid supplementationFolic Acid supplementation Single outcome Single outcome Neural Tube DefectsNeural Tube Defects

3. 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.

4. Falls Analytic Framework Single clinical treatment (with or without screening) Clinical Education/ Behavioral Counseling Home Hazard Modification Exercise/ Physical Therapy Multifactorial Assessment and Management Falls Adverse effects of interventions Fall-related fractures and serious injuries; Quality of Life; Mortality; Disability 3 Intervention* (alone or in combination) High-risk subpopulation Risk Evaluation of ages 65+ years Other positive outcomes of interventions 2b 2,2a 4 1,1a

5. Ideal Analytic Framework

6. Challenges: Nontraditional Outcomes  Years of Life gained may not be as important as Independent life or maintenance of function Independent life or maintenance of function Quality of life, etc Quality of life, etc  Caregiver outcomes Ability to plan by knowing that a patient is dementing 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 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 significantHow short a period of time is clinically significant Can outcomes be measured too far out and miss significant short term gains?Can outcomes be measured too far out and miss significant short term gains? Eg, Hospitalizations at 24 months after a fall intervention? Eg, Hospitalizations at 24 months after a fall intervention?  When to stop screening?

7. 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 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 GlassesGlasses Hearing AidsHearing Aids DenturesDentures What needs to be done to obtain coverage for these preventive services? What needs to be done to obtain coverage for these preventive services?

8.  Elizabeth Eckstrom: Synthesizing the Evidence  Marcel Salive: Medicare coverage of Preventive Services