A patient-centered research agenda for the care of the acutely ill older patient

Abstract

Hospitalists and others acute care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine (SHM) sponsored the Acute Care of Older Patients (ACOP) Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute (PCORI) framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through four steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a Partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of ten research questions in the following areas: advanced care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision-making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training.

Introduction

Older adults with high levels of medical complexity occupy in increasing fraction of beds in acute care hospitals in the US.^1,2 By 2007, patients 65 and older accounted for nearly half of adult inpatient days of care.¹ These patients are commonly cared for by hospitalists who number more than 40,000.³ While hospitalists are most often trained in Internal Medicine, they have typically received limited formal geriatrics training. Increasingly, access to experts in geriatric medicine is limited.⁴ Further, hospitalists and others who practice in acute care are limited by the lack of research to address the needs of the older adult population, specifically in the diagnosis and management of conditions encountered during acute illness.

To better support hospitalists in providing acute inpatient geriatric care, the Society of Hospital Medicine (SHM) partnered with the Association of Specialty Professors (ASP) to develop a research agenda to bridge this gap. Using methodology from the James Lind Alliance (JLA) and the Patient Centered Outcomes Research Institute (PCORI), SHM joined with older adult advocacy groups, professional societies of providers, and funders to create a geriatric-focused acute care research agenda, highlighting 10 key research questions.^5–7 The goal of this approach is “to produce and promote high integrity, evidence-based information that comes from research guided by patients, caregivers, and the broader healthcare community.”⁸ In this paper, we describe the methodology and results of this agenda-setting process, referred to as the Acute Care of Older Patients Priority Setting Partnership.

Methods

Overview

This project focused on topic generation, the first step in the PCORI framework for identification and prioritization of research areas.⁵ We employed a specific and defined methodology to elicit and prioritize potential research topics incorporating input from representatives of older patients, family caregivers, and health care providers.⁶

To elicit this input, we chose a collaborative and consultative approach to stakeholder engagement, drawing heavily from the published work of the James Lind Alliance – an initiative promoting patient-clinician partnerships in health research developed in the United Kingdom.⁶ We previously described the approach elsewhere.⁷

The ACOP process for determining the research agenda consisted of four steps: 1) convene, 2) consult, 3) collate, and 4) prioritize.⁶ Through these steps, detailed below, we were able to obtain input from a broad group of stakeholders, and engage the stakeholders in a process of reducing and refining our research questions.

1. Convene: The steering committee (the paper’s authors) convened a stakeholder partnership group that included stakeholders representing patients and caregivers, advocacy organizations for the elderly, organizations that address diseases and conditions common among hospitalized older patients, provider professional societies (e.g., hospitalists, subspecialists, and allied health professions), payers, and funders. Patient, caregiver, and advocacy organizations were identified based on their engagement in aging and health policy advocacy by Society of Hospital Medicine staff and one author who had completed a Health and Aging Policy Fellowship (HW).

   The steering committee issued email invitations to stakeholder organizations, making initial inquiries through professional staffs and relevant committee chairs. Second inquiries were made via email to each organization’s volunteer leadership. We developed a webinar that outlined the overall research agenda setting process and distributed the webinar to all stakeholders. The stakeholder organizations were asked to commit to 1) surveying their memberships and 2) participating actively in prioritization by email and at a one-day meeting in Washington DC.

2. Consult: Each stakeholder organization conducted a survey of its membership via an internet-based survey in the summer of 2013 (Appendix A). Stakeholder organizations were asked to provide up to 75 survey responses each. Though a standard survey was used, the steering committee was not prescriptive in the methodology of survey distribution to accommodate the structure and communication methods of the individual stakeholder organizations. Survey respondents were asked to identify up to five unanswered questions relevant to the acute care of older persons and also provide demographic information.

3. Collate: In the collating process, we clarified and categorized the unanswered questions submitted in the individual surveys. Each question was initially reviewed by one of the members of the steering committee, using explicit criteria (Appendix B). Questions that did not meet all four criteria were removed. For questions that met all criteria, we clarified language, combined similar questions, and categorized each question. Categories were created in a grounded process, in which individual reviewers assigned categories based on the content of the questions. Each question could be assigned to up to two categories. Each question was then reviewed by a second member of the steering committee using the same four criteria. As part of this review, similar questions were consolidated, and when possible, questions were rewritten in a standard format.⁶

   Finally, the steering committee reviewed previously published research agendas looking for additional relevant unanswered questions, specifically the New Frontiers Research Agenda created by the American Geriatrics Society in conjunction with participating subspecialty societies,⁹ the Cochrane library, and other systematic reviews identified in the literature via PubMed search.^10–15

4. Prioritize: The resulting list of unanswered questions was prioritized in two phases. First, the list was emailed to all stakeholder organizations. The organizations were asked to vote on their top 10 priorities from this list using an online ballot, assigning 10 points to their highest priority down to 1 point for their lowest priority. In so doing, they were asked to consider explicit criteria (Appendix B). Each organization had only one ballot and could arrive at their top 10 list in any manner they wished. The balloting from this phase was used to develop a list of unanswered questions for the second round of in-person prioritization. Each priority’s scores were totaled across all voting organizations. The 29 priorities with the highest point totals were brought to the final prioritization round because of a natural cut-point at priority number 29, rather than number 30.

   For the final prioritization round, the steering committee facilitated an in-person meeting in Washington, DC in October of 2013 using nominal group technique (NGT) methodologies to arrive at consensus.¹⁶ During this process stakeholders were asked to consider additional criteria (Appendix B).

Results

Table 1 lists the organizations who engaged in one or more parts of the topic generation process. Eighteen stakeholder organizations agreed to participate in the convening process. Ten organizations did not respond to our solicitation and one declined to participate.

Table 1.

Stakeholder Organizations Participating in the Acute Care of Older Persons Priority Setting Partnership

Organization (N=18)	Consultation % of Survey Responses (N=580)	Prioritization Round 1	Prioritization Round 2
Alzheimer’s Association	7.0%	Yes	Yes
American Academy of Neurology	3.4%	Yes	Yes
American Association of Retired Persons	0.8%	No	No
American College of Cardiology	11.4%	Yes	Yes
American College of Emergency Physicians	1.3%	No	No
American College of Surgeons	1.0%	Yes	Yes
American Geriatrics Society	7.6%	Yes	Yes
American Hospital Association	1.7%	Yes	No
Centers for Medicare and Medicaid Services	0.8%	Yes	Yes
Gerontological Society of America	18.9%	Yes	Yes
National Alliance for Caregiving	1.0%	Yes	Yes
National Association of Social Workers	5.9%	Yes	Yes
National Coalition for Healthcare	0.6%	No	No
National Institute on Aging	2.1%	Yes	Yes
National Partnership for Women and Families	0.0%	Yes	Yes
Nursing Improving Care for Healthsystem Elders	28.6%	Yes	No
Society of Critical Care Medicine	12.0%	Yes	Yes
Society of Hospital Medicine	4.6%	Yes	Yes

Seventeen stakeholder organizations obtained survey responses from a total of 580 individuals (range 3–150 per organization) who were asked to identify important unanswered questions in the acute care of older persons. Survey respondents were typically female (77%), white (85%), aged 45–65 (65%), and identified themselves as health professionals (90%). Twenty-six percent of respondents also identified as patients or family caregivers. Their surveys included 1,299 individual questions.

Figure 1 summarizes our collation and prioritization process and reports the numbers of questions resulting at each stage. Nine hundred nineteen questions were removed during the first review conducted by Steering Committee members, and 31 question categories were identified. An additional 305 questions were removed in the second review, with 75 questions remaining. As the final step of the collating process, literature review identified 39 relevant questions not already suggested or moved forward through our consultation and collation process. These questions were added to the list of unanswered questions.

Figure 1. Flow Diagram to Develop Top 10 Unanswered Questions from Stakeholder Survey Results.

The 1299 unanswered questions were reduced to a final list of 10 high priority research topics through a 2-step collation process and a 2-step prioritization process depicted in the flow diagram.

In the first round of prioritization, this list of 114 questions was emailed to each stakeholder organization (Table 1). After the stakeholder voting process was completed, 29 unanswered questions remained (Appendix C). These questions were refined and prioritized in the in-person meeting to create the final list of 10 questions. The stakeholders present in the meeting represented 13 organizations (Table 1). Using the nominal group process with several rounds of small group breakouts and large group deliberation, 9 of the top ten questions were selected from the list of 29. One additional highly relevant question that had been removed earlier in the collation process regarding workforce was added back by the stakeholder group.

This prioritized research agenda appears in Table 2 and below, organized alphabetically by topic.

Table 2.

Top Ten Unanswered Questions in the Acute Care of Older Persons

Topic	Scope of problem	What is known	Unanswered Question	Proposed Dimensions
Advanced Care Planning	Older persons who lack decision making capacity often do not have surrogates or clear goals of care documented.19 Advanced care directives are associated with an increase in patient autonomy and empowerment, and while 15 to 25% of adults completed the documentation in 200420, a recent study found completion rates have increased to 72%.21	Nursing home residents with advanced directives are less likely to be hospitalized.22,23 Advanced directive tools, such as POLST, work to translate patient preferences to medical order.24 Standardized patient transfer tools may help to improve transitions between nursing homes and hospitals.25 However, advanced care planning fails to integrate into courses of care if providers are unwilling or unskilled in using advanced care documentation.26	What approaches for determining and communicating goals of care across and within healthcare settings are most effective in promoting goal-concordant care for hospitalized older patients?	Potential interventions: Decision aids Standard interdisciplinary advanced care planning approach Patient advocates Potential outcomes might include: Completion of advanced directives and health care power of attorney Patient centered-outcomes*
Care transitions	Hospital readmission from home and skilled nursing facilities occurs within 30 days in up to a quarter of patients.27,28 The discharge of complex older hospitalized patients is fraught with challenges. The quality of the hospital discharge process can influence outcomes for vulnerable older patients.29–32 Studies measuring the quality of hospital discharge frequently find deficits in documentation of assessment of geriatric syndromes,33 poor patient/caregiver understanding,34,35 and poor communication and follow-up with post-acute providers.35–38	As many as 10 separate domains may influence the success of a discharge.39 There is limited evidence, regarding quality of care transitions for hospitalized older patients. The Coordinated-Transitional Care Program found that follow-up with telecommunication decreased readmission rates and improved transitional care for a high-risk condition veteran population.40 There is modest evidence for single interventions,41 while the most effective hospital-to-community care interventions address multiple processes in non-geriatric populations.39,42,43	What is the comparative effectiveness of transitional care models on patient-centered outcomes for hospitalized older adults?	Possible models: Established vs novel care-transition models Disease specific vs general approaches Accountable care models Caregiver and family engagement Community engagement Populations of interest: Patients with dementia Patients with multimorbidity Patients with geriatric syndromes Patients with psychiatric disease Racially and ethnically diverse patients Outcomes: Readmission Other adverse events Cost and healthcare utilization Patient-centered outcomes*
Delirium	Among older inpatients the prevalence of delirium varies with severity of illness. Among general medical patients in-hospital prevalence ranges from 10 to 25 %.44,45 In the ICU prevalence estimates are higher, ranging from 25% to as high as 80%.46,47 Delirium independently predicts increased length of stay,48,49 long term cognitive impairment,50,51 functional decline,51 institutionalization,52 and short and long term mortality.52–54	Multicomponent strategies have been shown to be effective in preventing delirium. A systematic review of 19 such interventions identified the most commonly included such as: 55 early mobilization, nutrition supplements, medication review, pain management, sleep enhancement, vision/hearing protocols, and specialized geriatric care. Studies have included general medical patients, post-operative patients, and patients in the ICU. The majority of these studies found reductions in either delirium incidence (including post-operative), delirium prevalence, or delirium duration. Although medications have not been effective in treating delirium in general medical patients,48 the choice and dose of sedative agents has been shown to impact delirium in the ICU.56–58	What practices are most effective for consistent recognition, prevention, and treatment of delirium subtypes (hypoactive, hyperactive, and mixed) among hospitalized older adults?	Outcomes to examine Delirium incidence (including post-operative) Delirium duration Delirium-coma free days Delirium prevalence at discharge Sub-syndromal delirium Potential prevention and treatment modalities: Family education or psychosocial interventions Pharmacologic interventions Environmental modifications Possible areas of focus: Special populations Patients with varying stages of dementia Patients with multi-morbidity Patients with geriatric syndromes Observation patients Diverse settings Emergency Department Perioperative Skilled Nursing/Rehab/Long-term acute care facilities
Dementia	13 – 63% of older persons in the hospital have dementia.59 Dementia is often unrecognized among hospitalized patients.60 The presence of dementia is associated with a more rapid functional decline during admission and delayed hospital discharge.59 Patients with dementia require more nursing hours, and are more likely to have complications61 or die in care homes rather than in their preferred site.59	Several tools have been validated to screen for dementia in the hospital setting.62 Studies have assessed approaches to diagnosing delirium in hospitalized patients with dementia.63 Cognitive and functional stimulation interventions may have a positive impact on reducing behavioral issues.64,65	Does universal assessment of hospitalized older adults for cognitive impairment (e.g. at presentation and/or discharge) lead to more appropriate application of geriatric care principles and improve patient centered outcomes?	Potential interventions: Dementia or delirium care Patient/family communication and engagement strategies Maintenance/recovery of independent functional status Potential outcomes: Patient-centered outcomes* Length of stay, cost, and healthcare utilization (including palliative care) Immediate invasive vs. early conservative treatments pursued
Depression	Depression is a common geriatric syndrome among acutely ill older patients, occurring in up to 45% of patients.66,67 Rates of depression are similar among patients discharged following a critical illness, with somatic, rather than cognitive-affective, complaints being the most prevalent.68 Depression among inpatients or immediately following hospitalization independently predicts worse functional outcomes,69 cognitive decline,70 hospital readmission,71,72 and long term mortality.69,73 Finally, geriatric patients are known to respond differently to medical treatment.74,75	Although highly prevalent, depression is poorly recognized and managed in the inpatient setting. Depression is recognized in only ~50% of patients, with previously undiagnosed or untreated depression being at highest risk for being missed.76 The role of treatment of depression in the inpatient setting is poorly understood, particularly for those with newly recognized depression or depressive symptoms. Some novel collaborative care and telephone outreach programs have led to increases in depression treatment in patients with specific medical and surgical conditions, and resulting in early promising mental health and comorbid outcomes.77,78 The efficacy of such programs for older patients is unknown.	Does identifying depressive symptoms during a hospital stay and initiating a therapeutic plan prior to discharge improve patient-centered and/or disease specific outcomes?	Possible areas of focus: Comprehensive geriatric and psychosocial assessment; Inpatient vs. outpatient initiation of pharmacological therapy Integration of confusion assessment method into therapeutic approaches Linkages with outpatient mental health resources
Medications	Medication exposure, particularly potentially inappropriate medications is common in hospitalized elders.79 Medication errors—of dosage, type, and discrepancy between what a patient takes at home and what is known to his/her prescribing physician—are common and adversely affects patient safety.80 Geriatric populations are disproportionately affected, especially those taking more than 5 prescription medications per day.81	Numerous strategies – including electronic alerts, screening protocols, and potentially inappropriate medication lists (Beers list, Screening Tool of Older People’s potentially inappropriate Prescriptions (STOPP) exist, though the optimal strategies to limit the use of potentially inappropriate medications is not yet known.82–84	What systems interventions improve medication management for older adults (i.e., appropriateness of medication choices and dosing, compliance, cost) in hospital and post-acute care?	Possible areas of focus: Use of healthcare information technology Communication across sites of care Reducing medication-related adverse events Engagement of family caregivers Patient-centered strategies to simplify regimens
Models of Care	Hospitalization marks a time of high risk for older patients. Up to half die during hospitalization or within the year following the hospitalization. There is high risk of nosocomial events, and more than a third experience a decline in health resulting in longer hospitalizations and/or placement in extended care facilities.73,85,86	Comprehensive inpatient care for older adults (Acute Care for Elders Units, Geriatric Evaluation and Management Units, Geriatric consultation services) were studied in 2 meta-analyses, 5 RCT’s and 1 quasi-experimental study and summarized in a systematic review.87 The studies reported improved quality of care (1 of 1 paper), quality of life (3 of 4), functional autonomy (5 of 6), survival (3 of 6), and equal or lower health care utilization (7 of 8).	For which populations of hospitalized older adults does systematic implementation of geriatric care principles/processes improve patient-centered outcomes?	Potential populations: Patients of the emergency department, critical care, perioperative, and targeted medical/surgical units Examples of care principles: Geriatric assessment, early mobility, medication management, delirium prevention, advanced care planning, risk factor modification, caregiver engagement Potential outcomes: Patient centered outcomes* Cost
Physical Function	Half of older patients will lose functional capacity during hospitalization.88 Loss of physical function, particularly of lower extremities, is a risk factor for nursing home placement.89,90 Older hospitalized patients spend the majority (up to 80%) of their time lying in bed, even when they are capable of walking independently.91	Loss of independences with ADL capabilities is associated with longer hospital stays, higher readmission rates, and higher mortality risk.92 Excessive time in bed during a hospital stay is also associated with falls.93 Often, hospital nursing protocols and physician orders increase in-hospital immobility in patients.91,94 However, nursing driven mobility protocols can improve functional outcomes of older hospitalized patients.95,96	What is the comparative effectiveness of interventions that promote in-hospital mobility, improve and preserve physical function, and reduce falls among older hospitalized patients?	Potential interventions: Intensive physical therapy Incidental functional training Restraint reduction Medication management Potential outcomes: Discharge location Delirium, pressure ulcers, and falls
Surgery	An increasing number of persons over 65 are undergoing surgical procedures.97 These persons are at increased risk for developing delirium/cogitative dysfunction,98 loss of functional status,99 and exacerbations of chronic illness.97 Additionally, pain management may be harder to address in this population.100 Current outcomes may not reflect the clinical needs of elder surgical patients.101	Tailored drug selection and nursing protocols may prevent delirium.98 Post-operative cognitive dysfunction may require weeks for resolution. Identifying frail patients pre-operatively may lead to more appropriate risk stratification and improved surgical outcomes.99 Pain management strategies focused on mitigating cognitive impact and other effects may also be beneficial.100 Development of risk-adjustment tools specific to older populations, as well as measures of frailty and patient-centered care, have been proposed.101	What perioperative strategies can be used to optimize care processes and improve outcomes in older surgical patients?	Potential strategies: Preoperative risk assessment and optimization for frail or multimorbid older patients Perioperative management protocols for frail or multimorbid older patients Potential outcomes: Postoperative patient centered outcomes* Perioperative cost, health care utilization
Training	Adults over 65 comprise 13.2 % of the US population, but account for > 30% of hospital discharges and 50% of hospital days.86,102,103 By 2030, there will only be one geriatrician for every 3798 Americans > 75 years.104 Between 1997 and 2006, the odds that a hospitalist would treat a hospitalized Medicare patient rose 29% per year.105	Train the trainer programs for physicians include the Curriculum for the Hospitalized Aging Medical Patient (CHAMP), the Advancement of Geriatrics Education Scholars Program (AGESP), the Program for Advancing Geriatrics Education (PAGE). Education for nurses include the Nurses Improving the Care of Health System Elders (NICHE). Outcomes include improved self-confidence, attitudes, teaching skills, and geriatric care environment.106–108	What is the most effective approach to training hospital-based providers in geriatric and palliative care competencies?	Potential interventions: Mentored implementation Train the trainer Technical support

^*Patient-centered outcomes might include: quality of life, symptoms, cognition, and functional status.

1. Advanced care planning: What approaches for determining and communicating goals of care across and within healthcare settings are most effective in promoting goal-concordant care for hospitalized older patients?

2. Care Transitions: What is the comparative effectiveness of transitional care models on patient-centered outcomes for hospitalized older adults?

3. Delirium: What practices are most effective for consistent recognition, prevention, and treatment of delirium subtypes among hospitalized older adults?

4. Dementia: Does universal assessment of hospitalized older adults for cognitive impairment (e.g. at presentation and/or discharge) lead to more appropriate application of geriatric care principles and improve patient-centered outcomes?

5. Depression: Does identifying depressive symptoms during a hospital stay and initiating a therapeutic plan prior to discharge improve patient-centered and/or disease-specific outcomes?

6. Medications: What systems interventions improve medication management for older adults (i.e., appropriateness of medication choices and dosing, compliance, cost) in hospital and post-acute care?

7. Models of Care: For which populations of hospitalized older adults does systematic implementation of geriatric care principles/processes improve patient-centered outcomes?

8. Physical function: What is the comparative effectiveness of interventions that promote inhospital mobility, improve and preserve physical function, and reduce falls among older hospitalized patients?

9. Surgery: What perioperative strategies can be used to optimize care processes and improve outcomes in older surgical patients?

10. Training: What is the most effective approach to training hospital-based providers in geriatric and palliative care competencies?

Table 2 also contains a capsule summary of the scope of the problem addressed by each research priority, a capsule summary of related work in the content area (“what is known”) not intended as a systematic review, and proposed dimensions or sub-questions suggested by the stakeholders at the final prioritization meeting

Discussion

Older hospitalized patients account for an increasing number and proportion of hospitalized patients,^1,2 and hospitalists increasingly are responsible for inpatient care for this population.³ The knowledge required for hospitalists to deliver optimal care and improve outcomes has not kept pace with the rapid growth of either hospitalists or hospitalized elders. Through a rigorous prioritization process, we identified ten areas that deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient. Assessment, prevention, and treatment of geriatric syndromes in the hospital account for almost half of the priority areas. Additional research is needed to improve advanced care planning, develop new care models, and develop training models for future hospitalists competent in geriatric and palliative care competencies.

A decade ago, The American Geriatric Society and the John A. Hartford Foundation embarked upon a research agenda aimed at improving the care of hospitalized elders cared for by specialists (i.e., New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties).⁹ This effort differed in many important ways from the current priortization process. First, the New Frontiers agenda focused upon specific diseases, whereas the ACOP agenda addresses geriatric syndromes that cut across multiple diseases. Second, the New Frontiers agenda was made by researchers and based upon published literature, whereas the ACOP agenda involved the input of multiple stakeholders. Finally, the New Frontiers prioritized a research agenda across a number of Surgical specialties, Emergency Medicine, and Geriatric Rehabilitation. Hospital Medicine, however, was still early in its development and was not considered a unique specialty. Since that time, Hospital Medicine has matured into a unique specialty, with increased numbers of hospitalists,³ increased research in Hospital Medicine,¹⁷ and a separate re-certification pathway for Internal Medicine licensure.¹⁸ To date, there has not been a similar effort performed to direct geriatric research efforts for Hospital Medicine.

For researchers working in the field of in Hospital Medicine, this list of topics has several implications. First, as hospitalists are commonly generalists, hospitalist researchers may be particularly well-suited to study syndromes that cut across specialties. However, this does raise concerns about funding sources as most NIH institutes are disease-focused. Funders that are not disease-focused such as PCORI, NIA, NINR, and AHRQ, and private foundations (Hartford, RWJ, and Commonwealth) may be more fruitful sources of funding for this work, but funding may be challenging. Nonetheless, the increased focus on patient-centered work may increase funders’ interest in such work. Second, the topics on this list would suggest that interventions will not be pharmacologic but will focus on non-pharmacologic, behavioral, and social interventions. Similarly, outcomes of interest must expand beyond utilization metrics such as LOS and mortality, to include functional status and symptom management, and goal-concordant care. Hence, research in geriatric acute care will necessarily be multidisciplinary.

While these ten high priority areas have been selected, this prioritized list is inherently limited by our methodology. First, our survey question was not focused on a disease state, and this wording may have resulted in the list favoring geriatric syndromes rather than common disease processes. Additionally, the resulting questions encompass large research areas, and not specific questions about discrete interventions. Our results may also have been skewed by the types of engaged respondents who participated in the consultation, collating, and prioritization phases. In particular, we had a large response from geriatric medicine nurses while some stakeholder groups provided no survey responses. Thus, these respondents were not representative of all possible stakeholders, nor were the survey respondents necessarily representative of each of their organizations. Nonetheless, the participants self-identified as representative of diverse viewpoints that included patients, caregivers, and advocacy groups, with the majority of stakeholder organizations remained engaged through the completion of the process. Thus, the general nature of this agenda helps us focus upon larger areas of importance, leaving researchers the flexibility to choose to narrow focus on a specific research question that may include potential interventions and unique outcomes. Finally, our methodology may have inadvertently limited the number of patient and family caregiver voices in the process given our approach to large advocacy groups, our desire to be inclusive of health care professional organizations, and our survey methodology. Other methodologies may have reached more patients and caregivers, yet many health care professionals have served as family caregivers to frail elders requiring hospitalization and may have been in an ideal position to answer the survey.

In conclusion, several forces are shaping the future of acute inpatient care. These include the changing demographics of the hospitalized patient population, a rapid increase in the proportion of multi-morbid hospitalized older adults, an inpatient workforce (hospitalists, generalists and subspecialists) with potentially limited geriatrics training, and gaps in evidence-based guidance to inform diagnostic and therapeutic decision-making for acutely ill older patients. Training programs in Hospital Medicine should be aware of and could benefit from the resulting list of unanswered questions. Our findings also have implications for training to enrich education in geriatrics. Moreover, there is growing recognition that patients and other stakeholders deserve a greater voice in determining the direction of research. In addition to efforts to improve patient-centeredness of research, these areas have been uniquely identified by stakeholders as important, and hence are in line with newer priorities of PCORI. This project followed a road map resulting in a patient-centered research agenda at the intersection of Hospital Medicine and Geriatric Medicine.⁷ In creating this agenda, we relied heavily on the framework proposed by PCORI. We propose to pursue a dissemination and evaluation strategy for this research agenda as well as additional prioritization steps. We believe the adoption of this methodology will create a knowledge base that is rigorously derived and most relevant to the care of hospitalized older adults and their families. Its application will ultimately result in improved outcomes for hospitalized older adults.