title: Incorporating prognosis in the care of older adults with multimorbidity: description and evaluation of a novel curriculum.
abstract: BACKGROUND
  Prognosis is a critical consideration in caring for older adults with multiple chronic conditions, or "multimorbidity". Clinicians are not adequately trained in this area. We describe an innovative curriculum that teaches internal medicine residents how to incorporate prognosis in the care of older adults with multimorbidity.
  
  
  METHODS
  The curriculum includes three small-group sessions and a clinical exercise; it focuses on the assessment, communication, and application of prognosis to inform clinical decisions. The curriculum was implemented with 20 first-year residents at one university-based residency (intervention group). Fifty-two first-year residents from a separate residency affiliated with the same university served as controls. Evaluation included three components. A survey assessed acceptability. A pre/post survey assessed attitude, knowledge, and self-reported skills (Impact survey). Comparison of baseline and follow-up results used paired t-test and McNemar test; comparison of inter-group differences used t-test and Fisher's exact test. A retrospective, blinded pre/post chart review assessed documentation behavior; abstracted outcomes were analyzed using Fisher's exact test.
  
  
  RESULTS
  The curriculum was highly rated (4.5 on 5-point scale). Eighteen intervention group residents (90 %) and 29 control group residents (56 %) responded to the Impact survey. At baseline, there were no significant inter-group differences in any of the responses. The intervention group improved significantly in prognosis communication skills (5.2 to 6.6 on 9-point scale, p < 0.001), usage of evidence-based prognostic tools (1/18 to 14/18 responses, p < 0.001), and prognostic accuracy (1/18 to 9/18 responses, p = 0.005). These responses were significantly different from the control group at follow-up. Of 71 charts reviewed in each group, prognosis documentation in the intervention group increased from 1/25 charts (4 %) at baseline to 8/46 charts (17 %) at follow-up (p = 0.15). No prognosis documentation was identified in the control group at either time point. Inter-group difference was significant at follow-up (p = 0.006).
  
  
  CONCLUSIONS
  We developed and implemented a novel prognosis curriculum that had significant short-term impact on the residents' knowledge and communication skills as compared to a control group. This innovative curriculum addresses an important educational gap in incorporating prognosis in the care of older adults with multimorbidity.
authors.affiliation: Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building Center Tower, Suite 2200, Baltimore, MD, 21224, USA. nancyli@jhmi.edu.
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Schoenborn
authors.affiliation: Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building Center Tower, Suite 2200, Baltimore, MD, 21224, USA. cyboyd@jhmi.edu.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Boyd
authors.affiliation: Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building Center Tower, Suite 2200, Baltimore, MD, 21224, USA. dcayea1@jhmi.edu.
authors.forename: Danelle
authors.initials: D
authors.lastname: Cayea
authors.affiliation: Harborview Medical Center, University of Washington, Seattle, WA, USA. kmn15@uw.edu.
authors.forename: Kelly
authors.initials: K
authors.lastname: Nakamura
authors.affiliation: Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building Center Tower, Suite 2200, Baltimore, MD, 21224, USA. qxue1@jhu.edu.
authors.forename: Qian-Li
authors.initials: QL
authors.lastname: Xue
authors.affiliation: Medline Industries, Mundelein, IL, USA. anushree.ray@gmail.com.
authors.forename: Anushree
authors.initials: A
authors.lastname: Ray
authors.affiliation: Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building Center Tower, Suite 2200, Baltimore, MD, 21224, USA. mmcnabne@jhmi.edu.
authors.forename: Matthew
authors.initials: M
authors.lastname: McNabney
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D015897:Comorbidity; D003479:Curriculum; D004503:Education, Medical, Graduate / Q000379:methods*; D005260:Female; D005853:Geriatrics / Q000193:education*; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency / Q000458:organization & administration*; D008297:Male; D005791:Patient Care; D011379:Prognosis; D015397:Program Evaluation; D014481:United States