At a time of changing leadership, we look back on over 30 years of accomplishment by Brown’s Center for Gerontology and Healthcare Research, including major advances in the care and quality of life for older adults, and in the scientific methods used to measure and understand this population. And we look forward, toward the challenges presented by America’s fastest growing population group.
When Brown University’s Center for Gerontology and Healthcare Research was founded in 1987, American adults over the age of 65 made up a little more than twelve percent of the population. Today, older adults make up nearly seventeen percent of our population; estimates are that they will outnumber children by 2035, and will represent fully one-quarter of all Americans by the year 2060.
This major demographic transition is driving changes in health care needs, in systems of care, and in the resources required to provide that care. Since its formation over 30 years ago, the Center for Gerontology has been at the forefront of understanding those needs, how those systems of care function—and fail to function—and how best to utilize resources to provide optimal, high-quality care to older adults. It has accomplished these advances by harnessing national data and embracing multidisciplinary approaches to improving care. Over its three decades, the center has expanded to meet the demands of America’s fastest growing population group, supported by the creation of the School of Public Health in 2013. And it has prepared the way forward, by creating a culture of mentorship that supports training programs for tomorrow’s health leaders, and by laying the groundwork for innovative new methods that will carry the center’s research into the future.
The Center for Gerontology’s foundation was laid in part by the National Hospice Study. This major 1980s study, which predated the center’s founding, was led by Vincent Mor, Ph.D., professor of health services, policy and practice, who would go on to become director of the center, and Dr. David Greer, then dean of Brown’s Warren Alpert Medical School. Among the first of its kind, the study linked primary data from hospices across the US on thousands of terminally ill Medicare beneficiaries to Medicare data. In this way, investigators were able to examine the impact of hospice care on patient and family quality of life, as well as on health care costs incurred by patients. “We linked all of these data sets together and did comparisons of hospice and non-hospice care,” Mor recalled. “Our data made it possible for a new benefit to emerge, and were directly used to come up with the payment rates used for the new Medicare hospice benefit.”
Other large scale national studies followed, including one on patterns of care for elderly cancer patients and for the creation and evaluation of the nursing home Resident Assessment Instrument, which was part of the most sweeping reform to nursing home regulation since the passage of Medicare and Medicaid programs in the mid-1960s.
A more recent example of how faculty in the Center for Gerontology employ data to examine and improve elder health is the work of Professor Kali Thomas, Ph.D. studying the benefits of Meals on Wheels. Using identifiers of people who receive Meals on Wheels, such as nine-digit zip codes, and matching those data with Medicare claims, makes it possible for investigators to compare those who receive these community-based services to those who do not. “It’s that data structure matching. Even if it’s not perfect,” Mor said, “it gives you a signal to see what’s happening.” Creating and utilizing huge national data bases to better understand the health challenges of older people has always been a hallmark of the center. “We’ve pride ourselves on doing this nationally,” Mor said, “with integrated data whenever possible, using cutting-edge methods.”
A Public Health Oriented Physician
The Center for Gerontology’s founding director, Dr. Sidney Katz, was succeeded in 1988 by Professor Mor. When Mor took over leadership of the center, it had “three or four faculty, some administrative staff, some program staff, and a couple of computing staff,” Mor said. “We did not have a biostatician.” Then, in 1997, after nearly a decade building the center, Mor became the 5th and final Chair of Brown’s Department of Community Health. “I was both Chair and Center Director,” Mor said, “and that was too much.” So in 2000, Mor was succeeded as director of the center by Dr. Richard Besdine, then recruited as the first David S. Greer Professor of Geriatric Medicine.
Dr. Besdine, a geriatrician, gained his public health perspective during four years in federal service as the first Chief Medical Officer and Director of the Health Standards and Quality Bureau for the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services (CMS)). In this role, Besdine was responsible for setting standards, inspection, enforcement, and improvement of health care quality for the nation’s then-70 million Medicare beneficiaries and Medicaid recipients. “I went to CMS, and I came out with my brain changed,” Besdine said. “I had become a health-of-the-population geriatrician.”
Besdine’s unique position as a physician with a public health perspective was a major boon for the Center for Gerontology, facilitating several initiatives at Brown. One example is the curriculum redesign at the Warren Alpert Medical School. Because aging cuts across almost all other medical disciplines, Besdine, who had previously served as Interim Dean of Medicine and Biological Sciences at Brown, led a team of collaborators to integrate aging-related content throughout the Medical School’s curriculum. Today, thanks to Besdine’s vision, every physician who graduates from the Alpert Medical School is as good at taking care of elderly patients as they are at taking care of young and middle-aged patients.
Besdine also helped to pioneer a model in which geriatrics-trained hospital physicians are paired with orthopaedic surgeons to manage the care of seniors hospitalized for hip fracture. “The conceptual framework is very simple,” Besdine said. “Terrible things happen to old people in hospitals. They fall, they get delirium, they get pressure sores, they have adverse drug effects, they get hospital-acquired infections.” To prevent these outcomes, and knowing that geriatricians are best at identifying risk factors, Besdine’s idea was to pair orthopedic surgeons repairing hips with geriatricians who could conduct functional assessments of physical, cognitive, emotional, and social risk factors in order to prevent negative outcomes. “We comprehensively assess patients at entry, looking for risk factors and intervening immediately to improve outcomes,” Besdine said. The program, which has been shown to save lives and reduce costs, has been extended beyond hip fractures to include other clinical conditions. It continues to be tested, evaluated, and expanded to hospitals and health systems around the country today.
Improving Quality of Life
A major theme of the Center for Gerontology’s work has been an emphasis on improving the quality of life for older people. An example of how withholding care can actually improve outcomes and quality of life, is center research led by Joan Teno, MD, MS, into the use of feeding tubes for elderly patients with advanced dementia.
Dementia, afflicting over 5 million Americans and their families today, often affects a patient’s ability to eat. Feeding tubes, a surgical intervention to improve nutrition, were widely in use a decade ago, despite evidence that they do not improve survival rates or quality of life for elderly patients with advanced dementia. Teno, then professor of community health, had documented striking variations in US feeding tube insertion rates. Together with colleagues in the center, Teno conducted a five-state survey with family members regarding feeding tube insertion to gain insight into the decision making process. The study found that in states with high rates of feeding tube insertion, discussions with physicians, if they happened at all, were often brief and did not include the risks associated with feeding tubes. “We need to improve decision making,” Teno’s study concluded, “so that the decision to insert a feeding tube is based on a process that elicits and respects patient’s wishes.” Teno’s studies added to a body of work that reduced the use of feeding tubes by 50 percent between 2000 and 2014, according to federal data.
A more recent study aimed at improving quality of life for dementia patients and their families is testing a program called Music & Memory. Early findings from the program, which involves providing residents in long-term care facilities with personalized music playlists delivered on digital devices, suggested that nursing homes certified in the program achieved reductions in behavioral problems and the use of antipsychotic prescriptions. Encouraged by these reports, researchers set out to systematically document how well the program positively affects the lives of people who are exposed.
Demonstrating Music & Memory’s impact is important because many people with dementia experience behavioral and psychological symptoms, such as aggression and agitation, that affect their quality of life and make caregiving difficult. In the absence of effective non-pharmacological interventions, health care providers often resort to using antipsychotic medications to control behaviors, despite warnings from the FDA about the increased risk of complications—and even death—when antipsychotics are used off-label in this population.
Researchers are now in the early stages of a large-scale trial of the program in nursing homes. By capturing detailed data on the intervention’s implementation and use, investigators hope to definitively link improvements in outcomes to the intervention itself. If proven effective, Music & Memory will be a low-cost and widely accessible strategy to improve care for people with dementia.
A Culture of Generativity: Training Future Elder Health Pioneers
From its inception, the Center for Gerontology has prioritized training and mentorship. Two fellowship programs, an Agency for Healthcare Research and Quality Postdoctoral Program and a Surdna Fellowship Program from the Surdna Foundation, embed postdoctoral trainees into the research teams of a funded faculty mentor to practice their skills, and then to carve out projects of their own. These formal two-year postdoctoral programs provide crucial career development experience and have a strong record of success. According to Dr. Besdine, “something like 90% of Vince’s more than 100 former trainees have federal funding for research. It’s an incredible track record.”
Junior faculty members benefit from the center’s culture of mentorship as well. A formal mentoring program, developed by Professor Susan Miller, pairs each junior faculty member with two senior faculty members. In the Center for Gerontology, “every senior faculty member is a mentor,” Dr. Besdine said, explaining with pride how the center’s collaborative structure nurtures students, trainees, and faculty alike. Professor Pedro Gozalo, for example, a health economist, came to the center and worked for several years as a methodologist statistician on many of Professor Mor’s projects. “He is now an independent investigator with funding of his own and is a major figure himself,” Besdine said. “And they still collaborate. It’s a wonderful story to tell.”
A Foundation Stone of the School of Public Health
When Dr. Besdine assumed leadership of the Center for Gerontology, it had grown to house over a dozen investigators, but it was still a part of Brown’s Division of Biology and Medicine. That began to change in 2002 when Professor Terrie Fox Wetle, who was then Associate Dean for Public Health in the Medical School, together with newly appointed Provost Robert Zimmer, developed their vision for a school of public health at Brown. It was not until July 1, 2013 that their idea was fully realized, with Wetle as founding Dean, but that date is “absolutely crucial in the history of the center,” Besdine said. The center “was now an integrated entity, it had an identity, and the ability to get grants that it was not eligible for previously.”
Today, five years since the founding of the School of Public Health, the Center for Gerontology and Healthcare Research is nationally and internationally recognized, with 29 principal investigators and 25 administrative and technical staff members. There has been a six-fold increase in research funding under Dr. Besdine’s leadership, from $3 million to $18 million annually, with a portfolio of more than 50 currently funded projects. “Being a part of the establishment of the School of Public Health changed the equation,” for the center, Besdine said.
After an over 50-year career and nearly two decades at Brown, Dr. Richard Besdine decided to hand off leadership of the Center for Gerontology. While he continues to teach, mentor, and conduct research, Besdine considers his most important job “to help the people who succeed me to be even more successful.”
His successor, appointed in September of 2019, is Theresa Shireman, Ph.D., MS, professor of health services, policy and practice. Shireman, who came to Brown in 2015, specializes in pharmaco-epidemiology and health economic evaluations. She has been an active member of the School’s faculty, serving in leadership positions, teaching graduate courses, mentoring clinician scientists and doctoral students, and advancing the School’s commitment to diversity and inclusion. Shireman has managed numerous contracts with the State Medicaid agencies and contributes to NIH funded research evaluating pharmaceutical use in vulnerable
As the center’s new director, she sees its direction moving from policy evaluation, toward a more proactive approach to improving care. “Much of the work we’ve all done has been looking at things that have already happened and identifying problems, but less about trying to solve them,” Shireman said. “I see the center interested in trying to fix things, rather than just evaluate them.
“I think we’ll have much more primary data collection,” she said about the center’s future, “much more primary research, much more intervention-focused research.” There is even discussion of a living laboratory where observations can be made, and data collected, analyzed, and responded to in real time.
As an example, she points to the recent National Institute on Aging grant, led by Professor Mor, which will create a massive collaborative research incubator to develop trials aimed at evaluating interventions for patients with dementia. The research incubator, called the Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory, will fund and provide expert assistance to up to 40 pilot trials that will test non-drug, care-based interventions for people living with dementia, and develop best practices for implementing and evaluating interventions for Alzheimer’s and dementia care and share them with the research community at large.
In her new role, and with the coming “aging avalanche,” Shireman also sees a need for the center to focus on those who are not yet elderly. “We need to focus on people 50-60 years of age,” she said. “They are the bullwhip that’s going to come through and hit the system. We’re going to try to change their trajectories, to understand how and what resources are needed to keep people in their homes. It’s not just about their health, it’s about income inequality, it’s about the health of their communities.”