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Putrik P, Grobler L, Lalor A, Ramsay H, Gorelik A, Karnon J, Parker D, Morgan M, Buchbinder R, O'Connor D. Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities. Cochrane Database Syst Rev 2024; 3:CD013880. [PMID: 38426600 PMCID: PMC10905654 DOI: 10.1002/14651858.cd013880.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents. OBJECTIVES Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. MAIN RESULTS We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. AUTHORS' CONCLUSIONS Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.
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Affiliation(s)
- Polina Putrik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Liesl Grobler
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Aislinn Lalor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Helen Ramsay
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alexandra Gorelik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jonathan Karnon
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Deborah Parker
- Faculty of Health, The University of Technology Sydney, Sydney, NSW, Australia
| | - Mark Morgan
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Segelman M, Hariharan D, Fletcher D, Gasdaska A, Ingber MJ, Khatutsky G, Bercaw L, Feng Z. Outcomes for Long-Stay Nursing Facility Residents Following On-Site Acute Care under a CMS Initiative. J Am Med Dir Assoc 2024; 25:12-16.e3. [PMID: 37301224 DOI: 10.1016/j.jamda.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The goal of this study was to describe outcomes of long-term nursing facility (NF) residents treated for one of 6 conditions on-site in the NF and to compare outcomes to those treated for the same conditions in the hospital. DESIGN Cross-sectional retrospective study. SETTINGS AND PARTICIPANTS The Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents-Payment Reform enabled participating NFs to bill Medicare for providing on-site care to eligible long-stay residents meeting specified severity criteria due to any of 6 medical conditions, as an alternative to hospitalization. For billing purposes, residents were required to meet clinical criteria severe enough to warrant hospitalization. METHODS We used the Minimum Data Set assessments to identify eligible long-stay NF residents. We used Medicare data to identify residents who were treated, either on-site or in the hospital, for the 6 conditions and measure outcomes including subsequent hospitalization and death. To compare residents treated in the 2 modes, we used logistic regression models and adjusted for demographics, functional and cognitive status, and comorbidities. RESULTS Among residents treated on-site for the 6 conditions, 13.6% were subsequently hospitalized and 7.8% died, within 30 days, compared to 26.5% and 17.0%, respectively, among those treated in the hospital. Based on multivariate analysis, those treated in the hospital were more likely to be readmitted (OR = 1.666, P < .001) or to die (OR = 2.251, P < .001). CONCLUSIONS AND IMPLICATIONS Although unable to fully account for differences in unobserved severity of illness between residents treated on-site vs in the hospital, our results do not indicate any harm, but rather a possible benefit, to being treated on-site.
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Affiliation(s)
| | - Dhwani Hariharan
- Brandeis University, Waltham, MA, USA; RTI International, Waltham, MA, USA
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Araki T, Yamazaki Y, Kimoto M, Goto N, Ikuyama Y, Takahashi Y, Kosaka M. Practical Utility of a Clinical Pathway for Older Patients with Aspiration Pneumonia: A Single-Center Retrospective Observational Study. J Clin Med 2023; 13:230. [PMID: 38202237 PMCID: PMC10779523 DOI: 10.3390/jcm13010230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/17/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Introduction: Clinical pathways (CPWs) are patient management tools based on a standardized treatment plan aimed at improving quality of care. This study aimed to investigate whether CPW-guided treatment has a favorable impact on the outcomes of hospitalized older patients with aspiration pneumonia. Method: This retrospective study included patients with aspiration pneumonia, aged ≥ 65 years, and hospitalized at a community hospital in Japan. CPW implementation was arbitrarily determined by the attending physician upon admission. Outcomes were compared according to with or without the CPW (CPW-group and non-CPW groups). Propensity score (PS)-based analyses were used to control for confounding factors. Logistic regression analyses were conducted to evaluate the impact of CPW on the clinical course and outcomes. Results: Of 596 included patients, 167 (28%) received the CPW-guided treatment. The mortality rate was 16.4%. In multivariable model, CPW implementation did not increase the risk for total and 30-day mortality, and resulted in shorter antibiotic therapy duration (≤9 days) (PS matching (PSM): odds ratio (OR) 0.50, p = 0.001; inverse provability of treatment weighting (IPTW): OR 0.48, p < 0.001) and length of hospital stay (≤21 days) (PSM: OR 0.67, p = 0.05; IPTW: OR 0.66, p = 0.03). Conclusions: This study support CPW utility in this population.
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Affiliation(s)
- Taisuke Araki
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan; (N.G.); (Y.I.)
- Center of Infectious Diseases, Nagano Prefectural Shinshu Medical Center, Suzaka 382-8577, Japan; (Y.Y.); (M.K.); (M.K.)
| | - Yoshitaka Yamazaki
- Center of Infectious Diseases, Nagano Prefectural Shinshu Medical Center, Suzaka 382-8577, Japan; (Y.Y.); (M.K.); (M.K.)
| | - Masanobu Kimoto
- Center of Infectious Diseases, Nagano Prefectural Shinshu Medical Center, Suzaka 382-8577, Japan; (Y.Y.); (M.K.); (M.K.)
| | - Norihiko Goto
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan; (N.G.); (Y.I.)
- Center of Infectious Diseases, Nagano Prefectural Shinshu Medical Center, Suzaka 382-8577, Japan; (Y.Y.); (M.K.); (M.K.)
| | - Yuichi Ikuyama
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan; (N.G.); (Y.I.)
- Center of Infectious Diseases, Nagano Prefectural Shinshu Medical Center, Suzaka 382-8577, Japan; (Y.Y.); (M.K.); (M.K.)
| | - Yuko Takahashi
- Division of Clinical Laboratory, Nagano Prefectural Shinshu Medical Center, Suzaka 382-8577, Japan;
| | - Makoto Kosaka
- Center of Infectious Diseases, Nagano Prefectural Shinshu Medical Center, Suzaka 382-8577, Japan; (Y.Y.); (M.K.); (M.K.)
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Javier Afonso-Argilés F, Comas Serrano M, Castells Oliveres X, Cirera Lorenzo I, García Pérez D, Pujadas Lafarga T, Ichart Tomás X, Puig-Campmany M, Vena Martínez AB, Renom-Guiteras A. Emergency department admissions and economic costs burden related to ambulatory care sensitive conditions in older adults living in care homes. Rev Clin Esp 2023; 223:585-595. [PMID: 37838224 DOI: 10.1016/j.rceng.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/10/2023] [Accepted: 09/27/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVES To assess the frequency of emergency department admissions (EDA) for ambulatory care sensitive conditions (ACSC) and non-ACSC among older adults living in care homes (CH), to describe and compare their demographic and clinical characteristics, the outcomes of the hospitalisation process and the associated costs. METHOD This multicenter, retrospective and observational study evaluated 2444 EDAs of older adults ≥ 65 years old living in care homes in 5 emergency departments in Catalonia (Spain) by ACSC and non-ACSC, in 2017. Sociodemographic variables, prior functional and cognitive status, and information on diagnosis and hospitalisation were collected. Additionally, the costs related with the EDAs were calculated, as well as a sensitivity analysis using different assumptions of decreased admissions due to ACSC. RESULTS A total of 2444 ED admissions were analysed. The patients' mean (SD) age was 85.9 (7.2) years. The frequency of ACSC-EDA and non-ACSC-EDA was 56.6% and 43.4%, respectively. Severe dependency and cognitive impairment were present in 56.6% and 78%, respectively, with no differences between the two groups. The three most frequent ACSC were falls/trauma (13.8%), chronic obstructive pulmonary disease/asthma (11.4%) and urinary tract infection (7.4%). The average cost per ACSC-EDA was є1,408.24. Assuming a 60% reduction of ACSC-EDA, the estimated cost savings would be є1.2 million. CONCLUSIONS Emergency admissions for ACSC from care homes have a significant impact on both frequency and costs. Reducing these conditions through targeted interventions could redirect the avoided costs towards improving care support in residential settings.
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Affiliation(s)
- F Javier Afonso-Argilés
- Servicio de Geriatría, Fundació Sanitària Mollet, Barcelona, Spain; Estudiante de doctorado de la Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - M Comas Serrano
- Servicio de Epidemiología y Evaluación, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Hospital del Mar, Barcelona, Spain; Miembro de la Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPS), Madrid, Spain
| | - X Castells Oliveres
- Servicio de Epidemiología y Evaluación, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Hospital del Mar, Barcelona, Spain; Miembro de la Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPS), Madrid, Spain
| | | | - D García Pérez
- Servicio de Urgencias, Fundació Althaia, Xarxa Assistencial Universitaria de Manresa, Barcelona, Spain
| | - T Pujadas Lafarga
- Servicio de Geriatría y Cuidados Paliativos, Badalona Serveis Assistencials, Barcelona, Spain
| | - X Ichart Tomás
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - M Puig-Campmany
- Servicio de Urgencias, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A B Vena Martínez
- Servicio de Geriatría, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - A Renom-Guiteras
- Miembro de la Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPS), Madrid, Spain; Servicio de Geriatría, Hospital del Mar, Barcelona, Spain
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5
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Leduc S, Wells G, Thiruganasambandamoorthy V, Cantor Z, Kelly P, Rietschlin M, Vaillancourt C. The hospital care and outcomes of long-term care patients treated by paramedics during an emergency call: exploring the potential impact of 'treat-and-refer' pathways and community paramedicine. CAN J EMERG MED 2023; 25:873-883. [PMID: 37715067 DOI: 10.1007/s43678-023-00590-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/22/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Adults living in long-term care (LTC) are at increased risk of harm when transferred to the emergency department (ED), and programs targeting treatment on-site are increasing. We examined characteristics, clinical course, and disposition of LTC patients transported to the ED to examine the potential impact of alternative models of paramedic care for LTC patients. METHODS We conducted a health records review of paramedic and ED records between April 1, 2016, and March 31, 2017. We included emergency calls originating from LTC centers and patients transported to either ED campus of The Ottawa Hospital. We excluded scheduled or deferrable transfers, and patients with Canadian Triage and Acuity Scale of 1. We categorized patients into groups based on care they received in the ED. We calculated standardized differences to examine differences between groups. RESULTS We identified four groups: (1) patients requiring no treatment or diagnostics in the ED (7.9%); (2) patients receiving ED treatment within current paramedic directives and no diagnostics (3.2%); (3) patients requiring diagnostics or ED care outside current paramedic directives (54.9%); and (4) patients requiring admission (34.1%). CONCLUSION This study found 7.9% of LTC patients transported to the ED did not receive diagnostics, medications, or treatment, and overall 11.1% of patients could have been treated by paramedics within current medical directives using 'treat-and-refer' pathways. This group could potentially expand utilizing community paramedics with expanded scopes of practice.
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Affiliation(s)
- Shannon Leduc
- Ottawa Paramedic Service, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - George Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Venkatesh Thiruganasambandamoorthy
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Zach Cantor
- Ottawa Paramedic Service, Ottawa, ON, Canada
| | - Peter Kelly
- Ottawa Paramedic Service, Ottawa, ON, Canada
| | | | - Christian Vaillancourt
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Guisado-Clavero M, Ares-Blanco S, Serafini A, Del Rio LR, Larrondo IG, Fitzgerald L, Vinker S, van Pottebergh G, Valtonen K, Vaes B, Yilmaz CT, Torzsa P, Tilli P, Sentker T, Seifert B, Saurek-Aleksandrovska N, Sattler M, Petricek G, Petrazzuoli F, Petek D, Perjés Á, López NP, Neves AL, Murauskienė L, Lingner H, Nessler K, Heleno B, Krztoń-Królewiecka A, Kostić M, Korkmaz BÇ, Knežević S, Kirkovski A, Karathanos VT, Jandrić-Kočić M, Ivanna S, Ільков О, Hoffmann K, Hanževački M, Gómez-Johansson M, Gjorgjievski D, Domeyer PRJ, Peña MD, Divjak AĆ, Busneag IC, Brutskaya-Stempkovskaya E, Bayen S, Bakola M, Adler L, Assenova R, Astier-Peña MP, Gómez Bravo R. The role of primary health care in long-term care facilities during the COVID-19 pandemic in 30 European countries: a retrospective descriptive study (Eurodata study). Prim Health Care Res Dev 2023; 24:e60. [PMID: 37873623 PMCID: PMC10594530 DOI: 10.1017/s1463423623000312] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/31/2022] [Accepted: 05/25/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND AND AIM Primary health care (PHC) supported long-term care facilities (LTCFs) in attending COVID-19 patients. The aim of this study is to describe the role of PHC in LTCFs in Europe during the early phase of the pandemic. METHODS Retrospective descriptive study from 30 European countries using data from September 2020 collected with an ad hoc semi-structured questionnaire. Related variables are SARS-CoV-2 testing, contact tracing, follow-up, additional testing, and patient care. RESULTS Twenty-six out of the 30 European countries had PHC involvement in LTCFs during the COVID-19 pandemic. PHC participated in initial medical care in 22 countries, while, in 15, PHC was responsible for SARS-CoV-2 test along with other institutions. Supervision of individuals in isolation was carried out mostly by LTCF staff, but physical examination or symptom's follow-up was performed mainly by PHC. CONCLUSION PHC has participated in COVID-19 pandemic assistance in LTCFs in coordination with LTCF staff, public health officers, and hospitals.
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Affiliation(s)
- Marina Guisado-Clavero
- Investigation Support Multidisciplinary Unit for Primary Health Care and
Community North Area of Madrid, Madrid,
Spain
| | - Sara Ares-Blanco
- Federica Montseny Health Centre, Gerencia Asistencial
Atención Primaria, Servicio Madrileño de Salud, Madrid,
Spain; Instituto de Investigación Sanitaria Gregorio
Marañón, Madrid, Spain
| | - Alice Serafini
- Azienda Unità Sanitaria Locale di Modena; Laboratorio EduCare,
University of Modena and Reggio Emilia,
Italy
| | - Lourdes Ramos Del Rio
- Federica Montseny Health Centre, Gerencia Asistencial de
Atención Primaria, Servicio Madrileño de Salud, Madrid,
Spain
| | - Ileana Gefaell Larrondo
- Federica Montseny Health Centre, Gerencia Asistencial de
Atención Primaria, Servicio Madrileño de Salud, Madrid,
Spain
| | - Louise Fitzgerald
- Member of Irish College of General Practice (MICGP), Member
of Royal College of Physician (MRCSI), Ireland
| | - Shlomo Vinker
- Department of Family Medicine, Sackler Faculty of Medicine,
Tel Aviv University, Tel Aviv,
Israel; WONCA Europe President
| | - Gijs van Pottebergh
- Department of Public Health and Primary Health Care, KU
Leuven, Leuven, Belgium
| | - Kirsi Valtonen
- Communicable Diseases and Infection Control Unit, City of
Vantaa and University of Helsinki, Helsinki,
Finland
| | - Bert Vaes
- Department of Public Health and Primary Health Care, KU
Leuven, Leuven, Belgium
| | - Canan Tuz Yilmaz
- Lecturer, Bursa Uludağ University, Family
Medicine Department, Turkey
| | - Péter Torzsa
- Department of Family Medicine, Semmelweis
University, Hungary
| | - Paula Tilli
- Communicable Diseases and Infection Control Unit, City of
Vantaa and University of Helsinki, Helsinki,
Finland
| | | | - Bohumil Seifert
- Charles University, First Faculty of Medicine, Institute of
General Practice, Czech Republic
| | | | | | - Goranka Petricek
- Department of Family Medicine “Andrija Stampar” School of Public Health,
School of Medicine, University of Zagreb,
Croatia; Health Centre Zagreb West, Croatia
| | - Ferdinando Petrazzuoli
- Department of Clinical Sciences in Malmö, Centre for Primary Health Care
Research, Lund University, Malmö,
Sweden
| | - Davorina Petek
- Department of Family Medicine, Faculty of Medicine,
University of Ljubljana, Slovenia;
Chairperson of EGPRN
| | - Ábel Perjés
- Department of Family Medicine, University of
Semmelweis, Budapest, Hungary
| | - Naldy Parodi López
- Närhälsan Kungshöjd Health Centre, Gothenburg,
Sweden; Department of Pharmacology, Sahlgrenska Academy,
University of Gothenburg, Gothenburg,
Sweden
| | - Ana Luisa Neves
- Imperial College London, United Kingdom;
Faculty of Medicine, University of Porto,
Portugal
| | - Liubovė Murauskienė
- Department of Public Health, Institute of Health Sciences, Faculty of
Medicine, Vilnius University, Lithuania
| | - Heidrun Lingner
- Medizinische Hochschule Hannover, OE 5430, Carl Neuberg Str. 1,
30625Hannover, Germany
| | - Katarzyna Nessler
- Department of Family Medicine, UJCM at Uniwersytet
Jagielloński – Collegium Medicum, Poland
| | - Bruno Heleno
- Comprehensive Health Research Center, NOVA Medical School,
Universidade Nova de Lisboa; USF das Conchas,
Regional Health Administration Lisbon and Tagus Valley, Lisbon,
Portugal
| | | | - Milena Kostić
- Health Center “Dr Đorđe Kovačević”, Lazarevac,
Belgrade, Serbia
| | | | | | - Aleksandar Kirkovski
- Faculty of Medicine, Ss. Cyril and Methodius
University, Skopje, North Macedonia
| | - Vasilis Trifon Karathanos
- Laboratory of Hygiene and Epidemiology, Medical Department, Faculty of
Health Sciences, University of Ioannina-Greece; Family Doctor,
GHS, Larnaca, Cyprus
| | | | - Shushman Ivanna
- Department of Family Medicine and Outpatient Care,
UZHNU, Medical Faculty 2, Ukraine
| | - Оксана Ільков
- Department of Family Medicine and Outpatient Care, Medical Faculty 2,
Uzhhorod National University, Ukraine
| | - Kathryn Hoffmann
- Associate Professor and Medical Doctor for General Practice and Primary
Care, Medical University of Vienna, Austria
| | - Miroslav Hanževački
- Department of Family Medicine “Andrija Stampar” School of Public Health,
School of Medicine, University of Zagreb,
Croatia; Health Centre Zagreb West, Croatia
| | | | | | | | | | | | - Iliana-Carmen Busneag
- “Spiru Haret” University, Practising Family Doctor, Occupational
Health Expert, Bucharest, Romania
| | | | - Sabine Bayen
- Department of General Practice, University of Lille,
UFR3S, France
| | - Maria Bakola
- Research Unit for General Medicine and Primary Health Care, Faculty of
Medicine, School of Health Science, University of Ioannina,
Ioannina, Greece
| | - Limor Adler
- Department of Family Medicine, Sackler Faculty of Medicine,
Tel Aviv University, Tel Aviv,
Israel
| | - Radost Assenova
- Department Urology and General Practice, Faculty of Medicine,
Medical University of Plovdiv, Bulgaria
| | - María Pilar Astier-Peña
- Healthcare Quality Technical Assistant, Territorial Quality Unit, Camp de
Tarragona Healthcare Directorate, Catalan Institute of Health,
Catalonia Government, Spain; Semfyc, Wonca World Executive Board,
University of Zaragoza, GIBA IIS Aragon,
Spain
| | - Raquel Gómez Bravo
- Centre Hospitalier Neuro-Psychiatrique, CHNP,
Rehaklinik, Ettelbruck, Luxembourg
- Research Group Self-Regulation and Health; Institute for Health and
Behaviour, Department of Behavioural and Cognitive Sciences, Faculty of Humanities,
Education, and Social Sciences, Luxembourg University,
Luxembourg
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Toles M, Kistler C, Lin FC, Lynch M, Wessell K, Mitchell SL, Hanson LC. Palliative care for persons with late-stage Alzheimer's and related dementias and their caregivers: protocol for a randomized clinical trial. Trials 2023; 24:606. [PMID: 37743478 PMCID: PMC10518941 DOI: 10.1186/s13063-023-07614-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Limited access to specialized palliative care exposes persons with late-stage Alzheimer's disease and related dementias (ADRD) to burdensome treatment and unnecessary hospitalization and their caregivers to avoidable strain and financial burden. Addressing this unmet need, the purpose of this study was to conduct a randomized clinical trial (RCT) of the ADRD-Palliative Care (ADRD-PC) program. METHODS The study will use a multisite, RCT design and will be set in five geographically diverse US hospitals. Lead investigators and outcome assessors will be masked. The study will use 1:1 randomization of patient-caregiver dyads, and sites will enroll N = 424 dyads of hospitalized patients with late-stage ADRD with their family caregivers. Intervention dyads will receive the ADRD-PC program of (1) dementia-specific palliative care, (2) standardized caregiver education, and (3) transitional care. Control dyads will receive publicly available educational material on dementia caregiving. Outcomes will be measured at 30 days (interim) and 60 days post-discharge. The primary outcome will be 60-day hospital transfers, defined as visits to an emergency department or hospitalization ascertained from health record reviews and caregiver interviews (aim 1). Secondary patient-centered outcomes, ascertained from 30- and 60-day health record reviews and caregiver telephone interviews, will be symptom treatment, symptom control, use of community palliative care or hospice, and new nursing home transitions (aim 2). Secondary caregiver-centered outcomes will be communication about prognosis and goals of care, shared decision-making about hospitalization and other treatments, and caregiver distress (aim 3). Analyses will use intention-to-treat, and pre-specified exploratory analyses will examine the effects of sex as a biologic variable and the GDS stage. DISCUSSION The study results will determine the efficacy of an intervention that addresses the extraordinary public health impact of late-stage ADRD and suffering due to symptom distress, burdensome treatments, and caregiver strain. While many caregivers prioritize comfort in late-stage ADRD, shared decision-making is rare. Hospitalization creates an opportunity for dementia-specific palliative care, and the study findings will inform care redesign to advance comprehensive dementia-specific palliative care plus transitional care. TRIAL REGISTRATION ClinicalTrials.gov NCT04948866. Registered on July 2, 2021.
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Affiliation(s)
- M Toles
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - C Kistler
- Department of Family Medicine and Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - F C Lin
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M Lynch
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - K Wessell
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, and Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - L C Hanson
- Division of Geriatrics and Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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8
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Valk-Draad MP, Bohnet-Joschko S. [Nursing home-sensitive conditions and approaches to reduce hospitalization of nursing home residents]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:199-211. [PMID: 36625862 PMCID: PMC9830609 DOI: 10.1007/s00103-022-03654-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Interventions to reduce potentially risky hospitalizations among nursing home residents are highly relevant for patient safety and quality improvement. A catalog of nursing home-sensitive conditions (NHSCs) grounds the policy recommendations and interventions. METHODS In two previous research phases, an expert panel developed a catalog of 58 NHSCs using an adapted Delphi-procedure (the RAND/UCLA Appropriateness Method). This procedure was developed by the North American non-profit Research and Development Organisation (RAND) and clinicians of the University of California in Los Angeles (UCLA). We present the third phase of the project focused on the development of interventions to reduce NHSCs starting with an expert workshop. The workshop results were then evaluated by six experts from related sectors, supplemented, and systematically used to produce recommendations for action. Possible implementation obstacles were considered and the time horizon of effectiveness was estimated. RESULTS The recommendations address communication, cooperation, documentation and care competence as well as facility-related, financial, and legal aspects. Indication bundles demonstrate the relevance for the German healthcare system. To increase effectiveness, the experts advise a meaningful combination of individual recommendations. DISCUSSION By optimizing multidisciplinary communication and cooperation, combined with an- also digital - expansion of the infrastructure and the creation of institution-specific and legal prerequisites as well as remuneration structures, an estimated 35% of all hospitalizations, approximately 220,000 hospitalizations for Germany, could be prevented. The implementation expenditure could be refinanced by avoided hospitalization savings amounting to 768 million euros.
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Affiliation(s)
- Maria Paula Valk-Draad
- Lehrstuhl für Management und Innovation im Gesundheitswesen, Fakultät für Wirtschaft und Gesellschaft, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Deutschland
- Lehrstuhl für Community Health Nursing, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Deutschland
| | - Sabine Bohnet-Joschko
- Lehrstuhl für Management und Innovation im Gesundheitswesen, Fakultät für Wirtschaft und Gesellschaft, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Deutschland.
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9
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Boere TM, El Alili M, van Buul LW, Hopstaken RM, Verheij TJM, Hertogh CMPM, van Tulder MW, Bosmans JE. Cost-effectiveness and return-on-investment of C-reactive protein point-of-care testing in comparison with usual care to reduce antibiotic prescribing for lower respiratory tract infections in nursing homes: a cluster randomised trial. BMJ Open 2022; 12:e055234. [PMID: 36109036 PMCID: PMC9478864 DOI: 10.1136/bmjopen-2021-055234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES C-reactive protein point-of-care testing (CRP POCT) is a promising diagnostic tool to guide antibiotic prescribing for lower respiratory tract infections (LRTI) in nursing home residents. This study aimed to evaluate cost-effectiveness and return-on-investment (ROI) of CRP POCT compared with usual care for nursing home residents with suspected LRTI from a healthcare perspective. DESIGN Economic evaluation alongside a cluster randomised, controlled trial. SETTING 11 Dutch nursing homes. PARTICIPANTS 241 nursing home residents with a newly suspected LRTI. INTERVENTION Nursing home access to CRP POCT (POCT-guided care) was compared with usual care without CRP POCT (usual care). MAIN OUTCOME MEASURES The primary outcome measure for the cost-effectiveness analysis was antibiotic prescribing at initial consultation, and the secondary outcome was full recovery at 3 weeks. ROI analyses included intervention costs, and benefits related to antibiotic prescribing. Three ROI metrics were calculated: Net Benefits, Benefit-Cost-Ratio and Return-On-Investment. RESULTS In POCT-guided care, total costs were on average €32 higher per patient, the proportion of avoided antibiotic prescribing was higher (0.47 vs 0.18; 0.30, 95% CI 0.17 to 0.42) and the proportion of fully recovered patients statistically non-significantly lower (0.86 vs 0.91; -0.05, 95% CI -0.14 to 0.05) compared with usual care. On average, an avoided antibiotic prescription was associated with an investment of €137 in POCT-guided care compared with usual care. Sensitivity analyses showed that results were relatively robust. Taking the ROI metrics together, the probability of financial return was 0.65. CONCLUSION POCT-guided care effectively reduces antibiotic prescribing compared with usual care without significant effects on recovery rates, but requires an investment. Future studies should take into account potential beneficial effects of POCT-guided care on costs and health outcomes related to antibiotic resistance. TRIAL REGISTRATION NUMBER NL5054.
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Affiliation(s)
- Tjarda M Boere
- Department of Medicine for Older People, Amsterdam Public Health research institute, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Mohamed El Alili
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health research institute, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Rogier M Hopstaken
- Star-SHL Diagnostic Center, Etten-Leur, The Netherlands
- Department of General Practice, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health research institute, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Maurits W van Tulder
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences research institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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10
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Dollard J, Edwards J, Yadav L, Gaget V, Tivey D, Inacio M, Maddern G, Visvanathan R. Residents' perspectives of mobile X-ray services in support of healthcare-in-place in residential aged care facilities: a qualitative study. BMC Geriatr 2022; 22:525. [PMID: 35752763 PMCID: PMC9233760 DOI: 10.1186/s12877-022-03212-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
Background Mobile X-ray services (MXS) could be used to investigate clinical issues in aged care residents within familiar surroundings, reducing transfers to and from emergency departments and enabling healthcare to be delivered in residential aged care facilities. There is however little research exploring consumer perspectives about such services. The objective of this research was to explore the perspectives and preferences of residents about the provision of MXS in residential aged care facilities, including their knowledge about the service, perceived benefits, and factors that require consideration for effective implementation. Methods A qualitative study design was used. The setting for the study included four residential aged care facilities of different sizes from different parts of a South Australian city. Purposive sampling was used to recruit participants. 16 residents participated in semi-structured interviews that were audio-recorded and transcribed verbatim. Data were inductively derived using thematic analysis. Results Participants had a mean age of 85 years, 56% were female, 25% had dementia and 25% had had a mobile X-ray in the last 12 months. Four themes were developed. Participants preferred mobile X-rays, provided as healthcare-in-place, to improve accessibility to them and minimize physical and psychological discomfort. Participants had expectations about the processes for receiving mobile X-rays. Costs of X-rays to people, family and society were a consideration. Decision making required residents be informed about mobile X-rays. Conclusions Residents have positive views of MXS as they can receive healthcare-in-place, with familiar people and surroundings. They emphasised that MXS delivered in residential aged care facilities need to be of equivalent quality to those found in other settings. Increased awareness of mobile X-ray services is required. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03212-2.
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Affiliation(s)
- Joanne Dollard
- Adelaide Geriatrics Training and Research With Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 37a Woodville Rd, Woodville South, South Australia, 5011, Australia. .,Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, 37 Woodville Rd, Woodville South, South Australia, 5011, Australia.
| | - Jane Edwards
- Adelaide Geriatrics Training and Research With Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 37a Woodville Rd, Woodville South, South Australia, 5011, Australia.,Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, 37 Woodville Rd, Woodville South, South Australia, 5011, Australia
| | - Lalit Yadav
- Adelaide Geriatrics Training and Research With Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 37a Woodville Rd, Woodville South, South Australia, 5011, Australia.,Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, 37 Woodville Rd, Woodville South, South Australia, 5011, Australia
| | - Virginie Gaget
- Surgical Specialties, University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - David Tivey
- Surgical Specialties, University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Maria Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,UniSA Allied Health and Human Movement, University of South Australia, Adelaide, South Australia, 5001, Australia
| | - Guy Maddern
- Surgical Specialties, University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Renuka Visvanathan
- Adelaide Geriatrics Training and Research With Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 37a Woodville Rd, Woodville South, South Australia, 5011, Australia.,Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, 37 Woodville Rd, Woodville South, South Australia, 5011, Australia.,Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, Australia
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11
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Hendricksen M, Loizeau AJ, Habtemariam DA, Anderson RA, Hanson LC, D'Agata EM, Mitchell SL. Provider adherence to training components from the Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD) intervention. Contemp Clin Trials Commun 2022; 27:100913. [PMID: 35369403 PMCID: PMC8965910 DOI: 10.1016/j.conctc.2022.100913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 02/28/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background The Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD) was a cluster randomized clinical trial evaluating a multicomponent program to improve infection management among residents with advanced dementia. This report examines facility and provider characteristics associated with greater adherence to training components of the TRAIN-AD intervention. Methods Logistic regression was used to identify facility and provider characteristics associated with: 1. Training seminar attendance, 2. Online course completion, and 3. Overall adherence, defined as participation in neither seminar nor course, either seminar or course, or both seminar and course. Results Among 380 participating providers (nurses, N = 298; prescribing providers, N = 82) almost all (93%) participated in at least one training activity. Being a nurse was associated with higher likelihood of any seminar attendance (adjusted odds ratio (AOR) 5.37; 95% confidence interval (CI), 2.80–10.90). Providers who were in facilities when implementation begun (AOR, 3.01; 95% CI, 1.34–6.78) and in facilities with better quality ratings (AOR, 2.70; 95% CI, 1.59–4.57) were more likely to complete the online course. Prevalent participation (AOR, 2.01; 95% CI, 1.02–3.96) and higher facility quality (AOR, 2.44; 95% CI, 1.27–4.66) were also significantly associated with greater adherence to either seminar or online course. Conclusion TRAIN-AD demonstrates feasibility in achieving high participation among nursing home providers in intervention training activities. Findings also suggest opportunities to maximize adherence, such as enhancing training efforts in lower quality facilities and targeting of providers who join the facility after implementation start-up. High levels of participation was due in part to flexibility of training options and engagement, making it easily accessible. Stakeholder engagement on priority issues and the start-up period on site were important to get buy-in from participants. Lessons learned provide insight into improving adherence for interventions, particularly for NHs with lower resources.
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Affiliation(s)
- Meghan Hendricksen
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, United States
- Corresponding author. Hebrew SeniorLife Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, United States.
| | - Andrea J. Loizeau
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, United States
| | - Daniel A. Habtemariam
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, United States
| | - Ruth A. Anderson
- School of Nursing, University of North Carolina, Chapel Hill, NC, United States
| | - Laura C. Hanson
- Division of Geriatric Medicine, Palliative Care Program, University of North Carolina Chapel Hill, NC, United States
| | - Erika M.C. D'Agata
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - Susan L. Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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12
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Prendki V, Garin N, Stirnemann J, Combescure C, Platon A, Bernasconi E, Sauter T, Hautz W. LOw-dose CT Or Lung UltraSonography versus standard of care based-strategies for the diagnosis of pneumonia in the elderly: protocol for a multicentre randomised controlled trial (OCTOPLUS). BMJ Open 2022; 12:e055869. [PMID: 35523502 PMCID: PMC9083386 DOI: 10.1136/bmjopen-2021-055869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Pneumonia is a leading cause of mortality and a common indication for antibiotic in elderly patients. However, its diagnosis is often inaccurate. We aim to compare the diagnostic accuracy, the clinical and cost outcomes and the use of antibiotics associated with three imaging strategies in patients >65 years old with suspected pneumonia in the emergency room (ER): chest X-ray (CXR, standard of care), low-dose CT scan (LDCT) or lung ultrasonography (LUS). METHODS AND ANALYSIS This is a multicentre randomised superiority clinical trial with three parallel arms. Patients will be allocated in the ER to a diagnostic strategy based on either CXR, LDCT or LUS. All three imaging modalities will be performed but the results of two of them will be masked during 5 days to the patients, the physicians in charge of the patients and the investigators according to random allocation. The primary objective is to compare the accuracy of LDCT versus CXR-based strategies. As secondary objectives, antibiotics prescription, clinical and cost outcomes will be compared, and the same analyses repeated to compare the LUS and CXR strategies. The reference diagnosis will be established a posteriori by a panel of experts. Based on a previous study, we expect an improvement of 16% of the accuracy of pneumonia diagnosis using LDCT instead of CXR. Under this assumption, and accounting for 10% of drop-out, the enrolment of 495 patients is needed to prove the superiority of LDCT over CRX (alpha error=0.05, beta error=0.10). ETHICS AND DISSEMINATION Ethical approval: CER Geneva 2019-01288. TRIAL REGISTRATION NUMBER NCT04978116.
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Affiliation(s)
- Virginie Prendki
- Division of Internal Medicine for the Aged, Geneva University Hospitals, Thônex, Switzerland
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Nicolas Garin
- Division of General Internal Medicine, Riviera Chablais Hospitals, Rennaz, Switzerland
- Department of Internal Medicine Specialties, Geneva University Hospitals, Geneva, Switzerland
| | - Jerome Stirnemann
- Department of Internal Medicine Specialties, Geneva University Hospitals, Geneva, Switzerland
| | - Christophe Combescure
- Department of Health and Community Medicine, Geneva University Hospitals, Geneve, Switzerland
| | - Alexandra Platon
- Diagnostic Department, Division of Radiology, Geneva University Hospitals, Geneva, Switzerland
| | - Enos Bernasconi
- Division of Infectious Diseases, Ente Ospedaliero Cantonale, University of Southern Switzerland, Lugano, Switzerland
| | - Thomas Sauter
- Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Wolf Hautz
- Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland
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13
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Inoue Y, Nishi K, Mayumi T, Sasaki J. Factors in Avoidable Emergency Visits for Ambulatory Care-sensitive Conditions among Older Patients Receiving Home Care in Japan: A Retrospective Study. Intern Med 2022; 61:177-183. [PMID: 35034933 PMCID: PMC8851167 DOI: 10.2169/internalmedicine.7136-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Older adults have many health conditions that do not require hospitalization, such as cognitive decline and progression of frailty, so it is necessary to prevent avoidable emergency visits for ambulatory care-sensitive conditions (ACSCs) in this population. We therefore examine Freund's classification of reasons for hospitalization owing to ACSCs to identify factors involved in elderly patients visiting emergency departments in Japan. Methods This retrospective case-control study included patients who received emergency transport for medical treatment at Yushoukai Home Care Clinic Shinagawa in Japan between January 1, 2016, and April 30, 2019. We examined patients' medical records and categorized the reasons for emergency visit by ambulance in accordance with Freund's categories (physician related level, medical causes, patient level, and social level). In addition, we classified and compared patients who lived at home (Group A) with those living in a care facility for older adults (Group B). Results A total of 365 patients visited the emergency department (298 in Group A and 67 in Group B). Among these, we determined that emergency visits were potentially avoidable in 135 patients from Group A and 28 from Group B. The patient and social level categories accounted for 81% of potentially avoidable emergency visits. Confirmed advanced care planning (ACP) was significantly associated with avoidable emergency visit by ambulance in multivariate analyses. Conclusion To prevent emergency visits for ACSCs among older people, ACP should be encouraged.
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Affiliation(s)
- Yoshie Inoue
- Yushoukai Medical Corporation Association, Yushoukai Home Care Clinic Shinagawa, Japan
| | - Kazuo Nishi
- Yushoukai Medical Corporation Association, Yushoukai Home Care Clinic Shinagawa, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Jun Sasaki
- Yushoukai Medical Corporation Association, Japan
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14
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Implementation and Use of Point-of-Care C-Reactive Protein Testing in Nursing Homes. J Am Med Dir Assoc 2021; 23:968-975.e3. [PMID: 34626578 DOI: 10.1016/j.jamda.2021.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study evaluated logistics, process data, and barriers/facilitators for the implementation and use of C-reactive protein point-of-care testing (CRP POCT) for suspected lower respiratory tract infections (LRTIs) in nursing home (NH) residents. DESIGN This process evaluation was performed alongside a cluster randomized, controlled trial (UPCARE study) to evaluate the effect of CRP POCT on antibiotic prescribing for suspected LRTIs in NH residents. SETTING AND PARTICIPANTS Eleven NHs in the Netherlands. METHODS Data sources for process data regarding intervention quality included a questionnaire among NH staff, logs, reports, and CRP POCT-analyzer records. Barriers and facilitators for implementation were assessed in focus group interviews with physicians and nurses from 3 NHs. RESULTS Correct patient selection for CRP POCT and generally continued CRP POCT use indicated good fidelity. The initial training and training of new employees seemed to fit the need, but some POCT-user group sizes had increased over time, which could have impeded frequent use. Users were generally satisfied with CRP POCT and perceived its use feasible and relevant. Facilitators for implementation were initial commitment and active initiation, followed by continued attention and enthusiasm for building routine practice and trust. Short lines of communication between staff, short distance to the POCT-analyzer, 24/7 coverage of staff, and a clear task division facilitated continued attention and routine practice. CONCLUSIONS AND IMPLICATIONS This process evaluation showed sufficient quality of providing CRP POCT in Dutch NHs. We processed findings of intervention quality and implementation knowledge into key recommendations for CRP POCT implementation in this setting. Future research could focus on CRP POCT use in countries with different organization of care in NHs.
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Boere TM, van Buul LW, Hopstaken RM, van Tulder MW, Twisk JWMR, Verheij TJM, Hertogh CMPM. Effect of C reactive protein point-of-care testing on antibiotic prescribing for lower respiratory tract infections in nursing home residents: cluster randomised controlled trial. BMJ 2021; 374:n2198. [PMID: 34548288 PMCID: PMC8453309 DOI: 10.1136/bmj.n2198] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate whether C reactive protein point-of-care testing (CRP POCT) safely reduces antibiotic prescribing for lower respiratory tract infections in nursing home residents. DESIGN Pragmatic, cluster randomised controlled trial. SETTING The UPCARE study included 11 nursing home organisations in the Netherlands. PARTICIPANTS 84 physicians from 11 nursing home organisations included 241 participants with suspected lower respiratory tract infections from September 2018 to the end of March 2020. INTERVENTIONS Nursing homes allocated to the intervention group had access to CRP POCT. The control group provided usual care without CRP POCT for patients with suspected lower respiratory tract infections. MAIN OUTCOME MEASURES The primary outcome measure was antibiotic prescribing at initial consultation. Secondary outcome measures were full recovery at three weeks, changes in antibiotic management and additional diagnostics during follow-up at one week and three weeks, and hospital admission and all cause mortality at any point (initial consultation, one week, or three weeks). RESULTS Antibiotics were prescribed at initial consultation for 84 (53.5%) patients in the intervention group and 65 (82.3%) in the control group. Patients in the intervention group had 4.93 higher odds (95% confidence interval 1.91 to 12.73) of not being prescribed antibiotics at initial consultation compared with the control group, irrespective of treating physician and baseline characteristics. The between group difference in antibiotic prescribing at any point from initial consultation to follow-up was 23.6%. Differences in secondary outcomes between the intervention and control groups were 4.4% in full recovery rates at three weeks (86.4% v 90.8%), 2.2% in all cause mortality rates (3.5% v 1.3%), and 0.7% in hospital admission rates (7.2% v 6.5%). The odds of full recovery at three weeks, and the odds of mortality and hospital admission at any point did not significantly differ between groups. CONCLUSIONS CRP POCT for suspected lower respiratory tract infection safely reduced antibiotic prescribing compared with usual care in nursing home residents. The findings suggest that implementing CRP POCT in nursing homes might contribute to reduced antibiotic use in this setting and help to combat antibiotic resistance. TRIAL REGISTRATION Netherlands Trial Register NL5054.
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Affiliation(s)
- Tjarda M Boere
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Rogier M Hopstaken
- Primary Health Care Center, Hapert en Hoogeloon, Hapert, Netherlands
- Star-shl Diagnostic Centers, Etten-Leur, Netherlands
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Maurits W van Tulder
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jos W M R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Theo J M Verheij
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
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Ewig S, Kolditz M, Pletz M, Altiner A, Albrich W, Drömann D, Flick H, Gatermann S, Krüger S, Nehls W, Panning M, Rademacher J, Rohde G, Rupp J, Schaaf B, Heppner HJ, Krause R, Ott S, Welte T, Witzenrath M. [Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. Pneumologie 2021; 75:665-729. [PMID: 34198346 DOI: 10.1055/a-1497-0693] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta-Kranken-Anstalt Bochum
| | - M Kolditz
- Universitätsklinikum Carl-Gustav Carus, Klinik für Innere Medizin 1, Bereich Pneumologie, Dresden
| | - M Pletz
- Universitätsklinikum Jena, Institut für Infektionsmedizin und Krankenhaushygiene, Jena
| | - A Altiner
- Universitätsmedizin Rostock, Institut für Allgemeinmedizin, Rostock
| | - W Albrich
- Kantonsspital St. Gallen, Klinik für Infektiologie/Spitalhygiene
| | - D Drömann
- Universitätsklinikum Schleswig-Holstein, Medizinische Klinik III - Pulmologie, Lübeck
| | - H Flick
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Lungenkrankheiten, Graz
| | - S Gatermann
- Ruhr Universität Bochum, Abteilung für Medizinische Mikrobiologie, Bochum
| | - S Krüger
- Kaiserswerther Diakonie, Florence Nightingale Krankenhaus, Klinik für Pneumologie, Kardiologie und internistische Intensivmedizin, Düsseldorf
| | - W Nehls
- Helios Klinikum Erich von Behring, Klinik für Palliativmedizin und Geriatrie, Berlin
| | - M Panning
- Universitätsklinikum Freiburg, Department für Medizinische Mikrobiologie und Hygiene, Freiburg
| | - J Rademacher
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - G Rohde
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Pneumologie und Allergologie, Frankfurt/Main
| | - J Rupp
- Universitätsklinikum Schleswig-Holstein, Klinik für Infektiologie und Mikrobiologie, Lübeck
| | - B Schaaf
- Klinikum Dortmund, Klinik für Pneumologie, Infektiologie und internistische Intensivmedizin, Dortmund
| | - H-J Heppner
- Lehrstuhl Geriatrie Universität Witten/Herdecke, Helios Klinikum Schwelm, Klinik für Geriatrie, Schwelm
| | - R Krause
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Infektiologie, Graz
| | - S Ott
- St. Claraspital Basel, Pneumologie, Basel, und Universitätsklinik für Pneumologie, Universitätsspital Bern (Inselspital) und Universität Bern
| | - T Welte
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - M Witzenrath
- Charité, Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie, Berlin
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17
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Boo S, Lee J, Oh H. Cost of Care and Pattern of Medical Care Use in the Last Year of Life among Long-Term Care Insurance Beneficiaries in South Korea: Using National Claims Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17239078. [PMID: 33291790 PMCID: PMC7730132 DOI: 10.3390/ijerph17239078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 11/16/2022]
Abstract
In Korea, a substantial proportion of long-term care insurance (LTCI) beneficiaries die within 1 year of seeking the benefit. This study was conducted to evaluate the pattern of medical care use and care cost during the last year of life among Korean LTCI beneficiaries between 2009 and 2013 using the national claims data. The National Health Insurance’s Senior (NHIS-Senior) cohort was used for this retrospective study. The participants were LTCI beneficiaries aged 65 or over as of 2008 who died between 2009 and 2013 (N = 30,433). Medical costs during the last year of life were highest for those who used both medical care services and long-term care (LTC) services and increased as death approached. About half of the participants were hospitalized at the time of death. The use of LTC services at the time of death increased from 13.0 to 22.8%, while those who died at home decreased from 34 to 20%. This study suggests that the use of LTC services did not reduce medical costs by substituting unnecessary inpatient hospitalization. Quality of dying should be considered one of the goals of older adult care, and provisions should be made for palliative care at home or LTC facilities.
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Affiliation(s)
- Sunjoo Boo
- Research Institute of Nursing Science, College of Nursing, Ajou University, Suwon 16499, Korea
- Correspondence: (S.B.); (H.O.)
| | - Jungah Lee
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, 71, Daehak-ro, Jongno-gu, Seoul 03082, Korea;
| | - Hyunjin Oh
- College of Nursing, Gachon University, Incheon 98105, Korea
- Correspondence: (S.B.); (H.O.)
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18
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Which Nursing Home Residents With Pneumonia Are Managed On-Site and Which Are Hospitalized? Results from 2 Years' Surveillance in 14 US Homes. J Am Med Dir Assoc 2020; 21:1862-1868.e3. [PMID: 32873473 DOI: 10.1016/j.jamda.2020.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 07/14/2020] [Accepted: 07/19/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Pneumonia is a frequent cause of hospitalization among nursing home (NH) residents, but little information is available as to how clinical presentation and other characteristics relate to hospitalization, and the differential use of antimicrobials based on hospitalization status. This study examined how hospitalized and nonhospitalized NH residents with pneumonia differ. DESIGN Data from a 2-year prospective study of residents who participated in a randomized controlled trial. SETTING AND PARTICIPANTS All residents from 14 NHs in North Carolina followed for pneumonia over a 2-year period. METHODS Clinical features, antimicrobial treatment, hospitalization, and demographic data on residents with a pneumonia diagnosis were abstracted from charts; NH information was obtained from NH administrators. RESULTS A total of 509 pneumonia episodes were reported for 395 unique residents; the incidence was not higher in the winter months, and 28% were hospitalized. The likelihood of hospitalization did not differ by clinical characteristics except that residents with a respiratory rate >25 breaths per minute were more likely to be hospitalized. Being on hospice [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.5-7.4] and not having dementia (OR 1.9, 95% CI 1.1-3.2) also related to increased likelihood of hospitalization. Fluoroquinolone (usually levofloxacin) monotherapy was the most common treatment (54%) in both settings, and ceftriaxone monotherapy varied by hospitalization status (7% of hospitalized vs 16% treated on-site). Approximately 36% of nonhospitalized residents received antimicrobials for more than 7 days. CONCLUSIONS/IMPLICATIONS Respiratory rate is associated with hospitalization but was not documented for more than a quarter of residents, suggesting the clinical benefit of more consistently conducting this assessment. Differential hospitalization rates for persons with dementia and on hospice suggest that care is being tailored to individuals' wishes, but this assumption merits study, as does use of fluoroquinolones (due to side effects) and treatment duration (due to potential contribution to antibiotic resistance).
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19
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Interventions to improve oral health of older people: A scoping review. J Dent 2020; 101:103451. [PMID: 32810577 DOI: 10.1016/j.jdent.2020.103451] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/06/2020] [Accepted: 08/12/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES A range of interventions have been tested to improve oral health of older people. We performed a scoping review to map interventions' aims, outcome measures and findings, and to locate them on different levels of care. DATA We systematically screened for (1) controlled studies on (2) people over 65 years of age, (3) comparing at least two interventions to improve oral health. Interventions were summarized according to their aims and the employed intervention type, mapped on their level of action, and classified as primary/secondary/tertiary prevention. SOURCES Studies retrieved via MEDLINE, EMBASE, CINAHL. STUDY SELECTION Eighty-one studies (published 1997-2019, conducted mainly in high-income countries) were included. Sample sizes varied (n = 24-1987). Follow-up was 0.25-60 months. Most studies (64/81) found a statistically significant benefit of the intervention. A total of 13 different aims were identified, and a range of intervention types employed (e.g. educational interventions, professional oral healthcare, restorative treatment, fluoride application and, generally, dentifrices, mouthwashes, chewing gums/food supplements). Most studies were located on the carer/patient level (56/81 studies) or the system/policy-maker level (44/81). The majority of studies aimed for primary prevention (64/81). CONCLUSIONS Oral health improvement interventions are widely studied. However, study aims, methods and outcome measures are highly heterogeneous, which limits the ability for robust conclusions. Current research focusses on primary prevention on the level of patients/carers or system/policy-maker level. Future studies may want to consider interventions on dentists' level focussing on secondary prevention. These studies should rely on a core set of comprehensive, standardized set of outcome measures. CLINICAL SIGNIFICANCE While specific interventions seem efficacious to improve older people's oral health, the current body of evidence is neither comprehensive (significant gaps exists in relevant levels of the care process) nor comparable enough to draw robust conclusions.
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20
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Leduc S, Cantor Z, Kelly P, Thiruganasambandamoorthy V, Wells G, Vaillancourt C. The Safety and Effectiveness of On-Site Paramedic and Allied Health Treatment Interventions Targeting the Reduction of Emergency Department Visits by Long-Term Care Patients: Systematic Review. PREHOSP EMERG CARE 2020; 25:556-565. [PMID: 32644902 DOI: 10.1080/10903127.2020.1794084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Programs that seek to avoid emergency department (ED) visits from patients residing in long-term care facilities are increasing. We sought to identify existing programs where allied healthcare personnel are the primary providers of the intervention and, to evaluate their effectiveness and safety. METHODS We systematically searched Medline, CINAHL and EMBASE with terms relating to long-term care, emergency services, hospitalization and allied health personnel. We reviewed 11,176 abstracts and included 22 studies in our narrative synthesis, which we grouped by intervention category. RESULTS We found five categories of interventions including: 1) use of advanced practice nursing; 2) a program called Interventions to Reduce Acute Care Transfers (INTERACT); 3) end-of-life care; 4) condition specific interventions; and 5) use of extended care paramedics. Among studies measuring that outcome, 13/13 reported a decrease in ED visits, and 16/17 reported a decrease hospitalization in the intervention groups. Patient adverse events such as functional status and relapse were seldom reported (6/22) as were measures of emergency system function such as crowding/inability of paramedics to transfer care to the ED (1/22). Only 4/22 studies evaluated patient mortality and 3/4 found a non-statistically significant worsening. CONCLUSION We found five types of programs/interventions which all demonstrated a decrease in ED visits or hospitalization. However, most studies were observational and few assessed patient safety. Many identified programs focused on increased primary care for patients, and interventions addressing acute care issues, such as community paramedics, deserve more study.
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21
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Wu Y, Li S, Patel A, Li X, Du X, Wu T, Zhao Y, Feng L, Billot L, Peterson ED, Woodward M, Kong L, Huo Y, Hu D, Chalkidou K, Gao R. Effect of a Quality of Care Improvement Initiative in Patients With Acute Coronary Syndrome in Resource-Constrained Hospitals in China: A Randomized Clinical Trial. JAMA Cardiol 2020; 4:418-427. [PMID: 30994898 DOI: 10.1001/jamacardio.2019.0897] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Prior observational studies suggest that quality of care improvement (QCI) initiatives can improve the clinical outcomes of acute coronary syndrome (ACS). To our knowledge, this has never been demonstrated in a well-powered randomized clinical trial. Objective To determine whether a clinical pathway-based, multifaceted QCI intervention could improve clinical outcomes among patients with ACS in resource-constrained hospitals in China. Design, Setting, Participants This large, stepped-wedge cluster randomized clinical trial was conducted in nonpercutaneous coronary intervention hospitals across China and included all patients older than 18 years and with a final diagnosis of ACS who were recruited consecutively between October 2011 and December 2014. We excluded patients who died before or within 10 minutes of hospital arrival. We recruited 5768 and 0 eligible patients for the control and intervention groups, respectively, in step 1, 4326 and 1365 in step 2, 3278 and 3059 in step 3, 1419 and 4468 in step 4, and 0 and 5645 in step 5. Interventions The intervention included establishing a QCI team, training clinical staff, implementing ACS clinical pathways, sequential site performance assessment and feedback, online technical support, and patient education. The usual care was the control that was compared. Main Outcomes and Measures The primary outcome was the incidence of in-hospital major adverse cardiovascular events (MACE), comprising all-cause mortality, reinfarction/myocardial infarction, and nonfatal stroke. Secondary outcomes included 16 key performance indicators (KPIs) and the composite score developed from these KPIs. Results Of 29 346 patients (17 639 men [61%]; mean [SD] age for control, 64.1 [11.6] years; mean [SD] age for intervention, 63.9 [11.7] years) who were recruited from 101 hospitals, 14 809 (50.5%) were in the control period and 14 537 (49.5%) were in the intervention period. There was no significant difference in the incidence of in-hospital MACE between the intervention and control periods after adjusting for cluster and time effects (3.9% vs 4.4%; odds ratio, 0.93; 95% CI, 0.75-1.15; P = .52). The intervention showed a significant improvement in the composite KPI score (mean [SD], 0.69 [0.22] vs 0.61 [0.23]; P < .01) and in 7 individual KPIs, including the early use of antiplatelet therapy and the use of appropriate secondary prevention medicines at discharge. No unexpected adverse events were reported. Conclusions and Relevance Among resource-constrained Chinese hospitals, introducing a multifaceted QCI intervention had no significant effect on in-hospital MACE, although it improved a few of the care process indicators of evidence-based ACS management. Trial Registration ClinicalTrials.gov identifier: NCT01398228.
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Affiliation(s)
- Yangfeng Wu
- George Institute for Global Health at Peking University Health Science Center, Beijing, China.,Peking University Clinical Research Institute, Beijing, China
| | - Shenshen Li
- George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Anushka Patel
- George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Xian Li
- George Institute for Global Health at Peking University Health Science Center, Beijing, China.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Xin Du
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Tao Wu
- George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Yifei Zhao
- George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Lin Feng
- Peking University Clinical Research Institute, Beijing, China
| | - Laurent Billot
- George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Mark Woodward
- George Institute for Global Health, University of Oxford, Oxford, England.,Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Lingzhi Kong
- Chinese Prevention Medical Association, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Dayi Hu
- Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Kalipso Chalkidou
- Global Health and Development, Imperial College, London, United Kingdom
| | - Runlin Gao
- Department of Cardiology, Cardiovascular Institute and Fuwai Hospital, Beijing, China.,Chinese Academy of Medical Sciences, Beijing, China.,Peking Union Medical College, Beijing, China
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22
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Toppenberg M, Christiansen T, Rasmussen F, Nielsen C, Damsgaard EM. Mobile X-ray Outside the Hospital vs. X-ray at the Hospital Challenges Exposed in an Explorative RCT Study. Healthcare (Basel) 2020; 8:E118. [PMID: 32365932 PMCID: PMC7349166 DOI: 10.3390/healthcare8020118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND For frail patients, it may sometimes be preferable to carry out X-ray examinations at the patients' own home. The general state of such patients may worsen due to transport and change of environment when transported for examination at the hospital. OBJECTIVE The aim of the randomized controlled trial (RCT) was to investigate if mobile X-ray improves healthcare for fragile patients. The primary outcome was the number of hospitalizations. DATA SOURCES We collected all data using questionnaires and data from the Electronic Patient Record (ER). PARTICIPANTS Patients referred to a mobile X-ray examination living in nursing homes and homes for the elderly in the Aarhus Municipality (Denmark). INTERVENTION mobile X-ray examinations compared to those at the hospital. Study appraisal: Data were collected and stored using the computer programme Redcap. Stata was used for statistical calculations. One hundred and thirty-six patients were included in the RCT. We did not find significant differences between mobile X-ray (intervention) and X-ray at the hospital (control) concerning hospitalizations and number of hospital days. Challenges: We met several challenges when carrying out RCT in the planned study population. Doctors often withdraw the referral when they found out that their patient should go to the hospital instead of mobile X-ray. The nursing home staff often considered the patient too frail to allow the test person to ask questions post X-ray. We also met challenges in the randomization method resulting in bias in the first data collection, so we had to adjust the randomization method. CONCLUSIONS For the fragile patients in the present explorative study, mobile X-ray did not significantly reduce the number of hospitalizations compared to X-ray at the hospital. Yet, mobile X-ray may be a new important diagnostic tool for more precise treatment to the frailest patients for whom transportation to the hospital is too exhausting. We need studies with focus on this aspect. We also recommend future RCT studies in a population for which mobile X-ray has not yet been a possibility.
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Affiliation(s)
- Maria Toppenberg
- The Department of Radiology, Aarhus University Hospital, 8200 Aarhus, Denmark; (T.C.); (F.R.)
| | - Thomas Christiansen
- The Department of Radiology, Aarhus University Hospital, 8200 Aarhus, Denmark; (T.C.); (F.R.)
| | - Finn Rasmussen
- The Department of Radiology, Aarhus University Hospital, 8200 Aarhus, Denmark; (T.C.); (F.R.)
| | - Camilla Nielsen
- DEFACTUM, Social and Health Services and Labour Market, 8200 Aarhus, Denmark;
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23
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Russo A, Picciarella A, Russo R, Sabetta F. Clinical features, therapy and outcome of patients hospitalized or not for nursing-home acquired pneumonia. J Infect Chemother 2020; 26:807-812. [PMID: 32273175 DOI: 10.1016/j.jiac.2020.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/24/2020] [Accepted: 03/16/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND nursing home-acquired pneumonia (NHAP), is among the main causes of hospitalization and mortality of frail elderly patients. Aim of this study was analysis of patients residing in long-term care facilities (LTCF) and developing pneumonia to reach a better knowledge of criteria for hospitalization and outcomes. MATERIALS/METHODS this is a prospective, observational study in which patients residing in 3 LTCFs (metropolitan area of Rome, Italy) and developing pneumonia, hospitalized or treated in LTCF, were recruited and followed up from January 2017 to June 2019. Primary endpoint was 30-day mortality, secondary endpoint was analysis of risk factors associated with hospitalization. RESULTS Overall, 146 episodes of NHAP were enrolled in the study: 57 patients were treated in LTCF, while 89 patients were hospitalized. Overall incidence rates of NHAP varied from 2.6 to 7.5 per 1000 residents. Methicillin-resistant Staphylococcus aureus was the most frequently isolated pathogen (25%), and in 28 (55%) patients was documented a MDR pathogen. For hospitalized patients was reported a higher 30-day mortality (43.8% Vs 7%, p < 0.001). Multivariate analysis showed that severe pneumonia, neoplasm, chronic hepatitis, antibiotic monotherapy, and malnutrition were independent risk factors for hospitalization from LTCF. MDR pathogen, severe pneumonia, COPD, and moderate to severe renal disease were independently associated with death at 30 days. CONCLUSION frail elderly patients in LTCF have a high risk of MDR etiology with a higher risk to receive an inadequate antibiotic therapy and a fatal outcome. These results point to the need for increased provision of acute care and strategies in LTCF.
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Affiliation(s)
| | | | - Roberta Russo
- Internal Medicine Unit, Policlinico Casilino, Rome, Italy
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24
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McCarthy EP, Ogarek JA, Loomer L, Gozalo PL, Mor V, Hamel MB, Mitchell SL. Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations. JAMA Intern Med 2020; 180:385-394. [PMID: 31886827 PMCID: PMC6990757 DOI: 10.1001/jamainternmed.2019.6130] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population. OBJECTIVE To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017-before and after the introduction of national initiatives to reduce hospitalizations. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019. MAIN OUTCOMES AND MEASURES The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained. RESULTS The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%). CONCLUSIONS AND RELEVANCE The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.
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Affiliation(s)
- Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Mary Beth Hamel
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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25
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Stephens CE, Halifax E, David D, Bui N, Lee SJ, Shim J, Ritchie CS. "They Don't Trust Us": The Influence of Perceptions of Inadequate Nursing Home Care on Emergency Department Transfers and the Potential Role for Telehealth. Clin Nurs Res 2020; 29:157-168. [PMID: 31007055 PMCID: PMC10242499 DOI: 10.1177/1054773819835015] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
In this descriptive, qualitative study, we conducted eight focus groups with diverse informal and formal caregivers to explore their experiences/challenges with nursing home (NH) to emergency department (ED) transfers and whether telehealth might be able to mitigate some of those concerns. Interviews were transcribed and analyzed using a grounded theory approach. Transfers were commonly viewed as being influenced by a perceived lack of trust in NH care/capabilities and driven by four main factors: questioning the quality of NH nurses' assessments, perceptions that physicians were absent from the NH, misunderstandings of the capabilities of NHs and EDs, and perceptions that responses to medical needs were inadequate. Participants believed technology could provide "the power of the visual" permitting virtual assessment for the off-site physician, validation of nursing assessment, "real time" assurance to residents and families, better goals of care discussions with multiple parties in different locations, and family ability to say goodbye.
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Affiliation(s)
- Caroline E. Stephens
- Department of Community Health Systems, University of California, San Francisco, CA, USA
| | - Elizabeth Halifax
- Department of Physiological Nursing, University of California, San Francisco, CA, USA
| | - Daniel David
- Department of Community Health Systems, University of California, San Francisco, CA, USA
| | - Nhat Bui
- Asian Health Services, Oakland, CA, USA
| | - Sei J. Lee
- Division of Geriatrics, University of California, San Francisco, CA, USA
- San Francisco VA Healthcare System, San Francisco, CA, USA
| | - Janet Shim
- Department of Social and Behavioral Sciences, University of California, San Francisco, CA, USA
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Boere TM, van Buul LW, Hopstaken RM, Veenhuizen RB, van Tulder MW, Cals JWL, Verheij TJM, Hertogh CMPM. Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial. BMC Health Serv Res 2020; 20:149. [PMID: 32103747 PMCID: PMC7045632 DOI: 10.1186/s12913-020-5006-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/17/2020] [Indexed: 11/15/2022] Open
Abstract
Background Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting. Methods/design A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no). Discussion This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results. Trial registration Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.
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Affiliation(s)
- Tjarda M Boere
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.
| | | | - Ruth B Veenhuizen
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | | | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Theo J M Verheij
- National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands.,Department of General Practice, Julius Centrum, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.,National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands
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Zinsaz H, Calder G, Corallo C, Gibson PR, Poojary S, Moran C. Initial experiences of an in-reach service providing iron infusions in residential aged care facilities. Australas J Ageing 2020; 39:e454-e459. [PMID: 32090443 DOI: 10.1111/ajag.12776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/14/2020] [Accepted: 01/18/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the feasibility of developing an in-reach parenteral iron infusion service to residents of residential aged care facilities (RACFs). METHODS An audit comparing the use of iron infusions in RACFs prior to and following the introduction of an in-reach iron infusion service. RESULTS Of the 738 inpatient iron infusions administered to inpatients ≥65 years in the 12 months prior to the in-reach service, 52 (7%) lived in an RACF, with no significant adverse events reported. After implementation of an in-reach service, a total of 37 RACF residents received parenteral iron in the first 12 months of the service, with no significant adverse events reported. CONCLUSION It is possible to safely provide parenteral iron through an in-reach service to residents in RACF. Further research is required to identify the person-level benefits achieved by this service.
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Affiliation(s)
- Hamed Zinsaz
- Department of Aged Care, Alfred Health, Melbourne, Vic., Australia.,Department of Aged Care, Monash Health, Melbourne, Vic., Australia
| | - Georgina Calder
- Mobile Assessment and Treatment Service, Alfred Health, Melbourne, Vic., Australia
| | - Carmela Corallo
- Pharmacy Department, Alfred Health, Melbourne, Vic., Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Vic., Australia
| | - Suma Poojary
- Department of Aged Care, Alfred Health, Melbourne, Vic., Australia.,Mobile Assessment and Treatment Service, Alfred Health, Melbourne, Vic., Australia
| | - Chris Moran
- Department of Aged Care, Alfred Health, Melbourne, Vic., Australia.,Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Vic., Australia.,Department of Aged Care, Peninsula Health, Melbourne, Vic., Australia
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Chou HH, Tsou MT, Hwang LC. Nasogastric tube feeding versus assisted hand feeding in-home healthcare older adults with severe dementia in Taiwan: a prognosis comparison. BMC Geriatr 2020; 20:60. [PMID: 32059646 PMCID: PMC7023686 DOI: 10.1186/s12877-020-1464-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/06/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND All individuals with severe dementia should be offered careful hand feeding. However, under certain circumstances, people with severe dementia have a feeding tube placed. In Taiwan, tube feeding rate in demented older home care residents is increasing; however, the benefits of tube feeding in this population remain unknown. We compared the clinical prognosis and mortality of older patients with severe dementia receiving nasogastric tube feeding (NGF) or assisted hand feeding (AHF). METHODS Data from the in-home healthcare system between January 1 and December 31, 2017 were analyzed to identify 169 participants over 60 years of age in this retrospective longitudinal study. All subjects with severe dementia and complete functional dependence suffered from difficulty in oral intake and required either AHF or NGF. Data were collected from both groups to analyze pneumonia, hospitalization, and mortality rates. RESULTS A total of 169 subjects (56 males and 113 females, aged 85.9 ± 7.5 years) were analyzed. 39 required AHF and 130 NGF. All subjects were bedridden; 129 (76%) showed Barthel index < 10. Pneumonia risk was higher in the NGF group (48%) than in the AHF group (26%, p = 0.015). After adjusting for multiple factors in the regression model, the risk of pneumonia was not significantly higher in the NGF group compared with the AHF group. One-year mortality rates in the AHF and NGF groups were 8 and 15%, respectively, and no significant difference was observed after adjustment with logistic regression (aOR = 2.38; 95% CI, 0.58-9.70). There were no significant differences in hospitalization rate and duration. CONCLUSIONS For older patients with dementia requiring in-home healthcare, NGF is not associated with a significantly lower risk of pneumonia than AHF. Additionally, neither mortality nor hospitalization rates decreased with NGF. On the contrary, a nonsignificant trend of increased risk of pneumonia was observed in NGF group. Therefore, the benefits of NGF are debatable in older patients with severe dementia requiring in-home healthcare. Continued careful hand feeding could be an alternative to NG feeding in patients with severe dementia. Furthermore, large-scale studies on in-home healthcare would be required to support these results.
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Affiliation(s)
- Hsiao-Hui Chou
- Department of Family Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Meng-Ting Tsou
- Department of Family Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Lee-Ching Hwang
- Department of Family Medicine, Mackay Memorial Hospital, Taipei, Taiwan. .,Department of Medicine, Mackay Medical College, Taipei, Taiwan.
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Mylotte JM. Nursing Home-Associated Pneumonia, Part II: Etiology and Treatment. J Am Med Dir Assoc 2020; 21:315-321. [PMID: 32061505 PMCID: PMC7105974 DOI: 10.1016/j.jamda.2020.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/10/2020] [Indexed: 01/24/2023]
Abstract
This is the second of 2 parts of a narrative review of nursing home-associated pneumonia (NHAP) that deals with etiology and treatment in the nursing home. In the 1980s and 1990s, the etiology of NHAP was considered to be similar to community-acquired pneumonia (CAP). This belief was reflected in CAP guidelines until 2005 when the designation healthcare-associated pneumonia or HCAP was introduced and nursing home residents were included in the HCAP category. Patients in the HCAP group were thought to be at high risk for pneumonia because of multidrug resistant organisms and required empiric broad-spectrum antibiotic therapy much like people with hospital-acquired infection. Subsequent studies of the etiology of NHAP using sophisticated diagnostic testing found limited evidence of resistant organisms such as methicillin-resistant Staphylococcus aureus or resistant gram-negative organisms or atypical organisms. In terms of management of NHAP in the nursing home there are several considerations that are discussed: hospitalization decision, initial oral or parenteral therapy, timing of switch to an oral regimen if parenteral therapy is initially prescribed, duration of therapy with an emphasis on shorter courses, and follow-up during therapy including the use of the "antibiotic time out" protocol. The oral and parenteral antibiotic regimens recommended for treatment of NHAP in this report are based on limited information because there are no randomized controlled trials to define the optimum regimen. In conclusion, most residents with pneumonia can be treated successfully in the nursing home. However, there is an urgent need for a specific NHAP diagnosis and treatment guideline that will give providers guidance in the management of this infection in the nursing home.
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Affiliation(s)
- Joseph M Mylotte
- Professor Emeritus, Department of Medicine, Division of Infectious Diseases, Jacobs School of Medicine and Biomedical Science, State University of New York at Buffalo, Buffalo, NY.
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Loizeau AJ, D'Agata EMC, Shaffer ML, Hanson LC, Anderson RA, Tsai T, Habtemariam DA, Bergman EH, Carroll RP, Cohen SM, Scott EME, Stevens E, Whyman JD, Bennert EH, Mitchell SL. The trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias: study protocol for a cluster randomized controlled trial. Trials 2019; 20:594. [PMID: 31615540 PMCID: PMC6794759 DOI: 10.1186/s13063-019-3675-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infections are common in nursing home (NH) residents with advanced dementia but are often managed inappropriately. Antimicrobials are extensively prescribed, but frequently with insufficient evidence to support a bacterial infection, promoting the emergence of multidrug-resistant organisms. Moreover, the benefits of antimicrobials remain unclear in these seriously ill residents for whom comfort is often the goal of care. Prior NH infection management interventions evaluated in randomized clinical trials (RCTs) did not consider patient preferences and lack evidence to support their effectiveness in 'real-world' practice. METHODS This report presents the rationale and methodology of TRAIN-AD (Trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias), a parallel group, cluster RCT evaluating a multicomponent intervention to improve infection management for suspected urinary tract infections (UTIs) and lower respiratory tract infections (LRIs) among NH residents with advanced dementia. TRAIN-AD is being conducted in 28 facilities in the Boston, USA, area randomized in waves using minimization to achieve a balance on key characteristics (N = 14 facilities/arm). The involvement of the facilities includes a 3-month start-up period and a 24-month implementation/data collection phase. Residents are enrolled during the first 12 months of the 24-month implementation period and followed for up to 12 months. Individual consent is waived, thus almost all eligible residents are enrolled (target sample size, N = 410). The intervention integrates infectious disease and palliative care principles and includes provider training delivered through multiple modalities (in-person seminar, online course, management algorithms, and prescribing feedback) and an information booklet for families. Control facilities employ usual care. The primary outcome, abstracted from the residents' charts, is the number of antimicrobial courses prescribed for UTIs and LRIs per person-year alive. DISCUSSION TRAIN-AD is the first cluster RCT testing a multicomponent intervention to improve infection management in NH residents with advanced dementia. Its findings will provide an evidence base to support the benefit of a program addressing the critical clinical and public health problem of antimicrobial misuse in these seriously ill residents. Moreover, its hybrid efficacy-effectiveness design will inform the future conduct of cluster RCTs evaluating nonpharmacological interventions in the complex NH setting in a way that is both internally valid and adaptable to the 'real-world'. TRIAL REGISTRATION ClinicalTrials.gov, NCT03244917 . Registered on 10 August 2017.
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Affiliation(s)
- Andrea J Loizeau
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA.
| | - Erika M C D'Agata
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Michele L Shaffer
- Department of Statistics, University of Washington, Seattle, WA, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Palliative Care Program, Chapel Hill, NC, USA
| | - Ruth A Anderson
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - Timothy Tsai
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Daniel A Habtemariam
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Elaine H Bergman
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Ruth P Carroll
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Simon M Cohen
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Erin M E Scott
- Division of Palliative Care and Geriatrics, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Erin Stevens
- Division of Palliative Care and Geriatrics, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremy D Whyman
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Martin RS, Hayes BJ, Hutchinson A, Tacey M, Yates P, Lim WK. Introducing Goals of Patient Care in Residential Aged Care Facilities to Decrease Hospitalization: A Cluster Randomized Controlled Trial. J Am Med Dir Assoc 2019; 20:1318-1324.e2. [PMID: 31422065 DOI: 10.1016/j.jamda.2019.06.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/14/2019] [Accepted: 06/22/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The "Goals of Patient Care" (GOPC) process uses shared decision making to incorporate residents' prior advance care planning (ACP) or preferences into medical treatment orders, guiding health care decisions at a time of clinical deterioration should they be unable to voice their opinions. The objective was to determine whether GOPC medical treatment orders were more effective than ACP alone in preventing emergency department (ED) visits (no hospitalization), ED visits (with hospitalization), and deaths outside the residential aged care facility (RACF). DESIGN The study was a prospective cluster randomized controlled trial, with the intervention being the completion of GOPC process by a geriatrician, following a shared decision-making process, incorporating ACP documents or residents' preferences. SETTING AND PARTICIPANTS The study took place in 6 RACFs in Northern Metropolitan Melbourne, Australia. Eligible participants included all permanent residents in participating RACFs for whom written informed consent could be obtained. MEASURES The primary outcome was the effect on ED visits and hospitalizations at 6 months. Secondary outcomes included a difference in hospitalization rates at 3 and 12 months, total hospital bed-days, and in-RACF and in-hospital mortality rates. RESULTS More than 75% of residents participated, 181 randomized to Intervention and 145 to Control. The intervention did not result in a statistically significant change at 6 months; however, at 12 months, it reached statistical significance with 40% reduction in ED visits and hospitalizations compared with Control, with an incident rate ratio 0.63 [95% confidence interval (CI) 0.41-0.99, P = .044]. Mortality rates show increased likelihood of dying in the RACF, with statistical significance at 6 months at a relative risk ratio of 2.19 (95% CI 1.16-4.14, P = .016). CONCLUSIONS AND IMPLICATIONS In the RACF population, GOPC medical treatment orders were more effective than ACP alone for decreasing hospitalization and likelihood of dying outside the RACF. GOPC should be considered by both RACF staff and health services to decrease hospitalization and in-hospital mortality.
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Affiliation(s)
- Ruth S Martin
- University of Melbourne, Melbourne, Victoria, Australia.
| | | | - Anastasia Hutchinson
- Northern Health, Epping, Victoria, Australia; Deakin University, Geelong, Victoria, Australia
| | - Mark Tacey
- Northern Health, Epping, Victoria, Australia
| | - Paul Yates
- Northern Health, Epping, Victoria, Australia
| | - Wen Kwang Lim
- University of Melbourne, Melbourne, Victoria, Australia; Melbourne Health, Melbourne, Victoria, Australia
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Stall NM, Fischer HD, Fung K, Giannakeas V, Bronskill SE, Austin PC, Matlow JN, Quinn KL, Mitchell SL, Bell CM, Rochon PA. Sex-Specific Differences in End-of-Life Burdensome Interventions and Antibiotic Therapy in Nursing Home Residents With Advanced Dementia. JAMA Netw Open 2019; 2:e199557. [PMID: 31418809 PMCID: PMC6704739 DOI: 10.1001/jamanetworkopen.2019.9557] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/29/2019] [Indexed: 01/11/2023] Open
Abstract
Importance Nursing home residents with advanced dementia have limited life expectancies yet are commonly subjected to burdensome interventions at the very end of life. Whether sex-specific differences in the receipt of these interventions exist and what levels of physical restraints and antibiotics are used in this terminal setting are unknown. Objective To evaluate the population-based frequency, factors, and sex differences in burdensome interventions and antibiotic therapy among nursing home residents with advanced dementia. Design, Setting, and Participants This population-based cohort study from Ontario, Canada, used linked administrative databases held at ICES, including the Continuing Care Resident Reporting System Long-Term Care database, which contains data from the Resident Assessment Instrument Minimum Data Set, version 2.0. Nursing home residents (n = 27 243) with advanced dementia who died between June 1, 2010, and March 31, 2015, at 66 years or older were included in the analysis. Initial statistical analysis was completed in May 2017, and analytical revisions were conducted from November 2018 to January 2019. Exposure Sex of the nursing home resident. Main Outcomes and Measures Burdensome interventions (transitions of care, invasive procedures, and physical restraints) and antibiotic therapy in the last 30 days of life. Results The final cohort included 27 243 nursing home residents with advanced dementia (19 363 [71.1%] women) who died between June 1, 2010, and March 31, 2015, at the median (interquartile range) age of 88 (83-92) years. In the last 30 days of life, burdensome interventions were common, especially among men: 5940 (21.8%) residents were hospitalized (3661 women [18.9%] vs 2279 men [28.9%]; P < .001), 2433 (8.9%) had an emergency department visit (1579 women [8.2%] vs 854 men [10.8%]; P < .001), and 3701 (13.6%) died in an acute care facility (2276 women [11.8%] vs 1425 men [18.1%]; P < .001). Invasive procedures were also common; 2673 residents (9.8%) were attended for life-threatening critical care (1672 women [8.6%] vs 1001 men [12.7%]; P < .001), and 210 (0.8%) received mechanical ventilation (113 women [0.6%] vs 97 men [1.2%]; P < .001). Among the 9844 residents (36.1%) who had a Resident Assessment Instrument Minimum Data Set, version 2.0, completed in the last 30 days of life, 2842 (28.9%) were physically restrained (2002 women [28.3%] vs 840 men [30.4%]; P = .005). More than one-third (9873 [36.2%]) of all residents received an antibiotic (6599 women [34.1%] vs 3264 men [41.4%]; P < .001). In multivariable models, men were more likely to have a transition of care (adjusted odds ratio, 1.41; 95% CI, 1.33-1.49; P < .001) and receive antibiotics (adjusted odds ratio, 1.33; 95% CI, 1.26-1.41; P < .001). Only 3309 residents (12.1%; 2382 women [12.3%] vs 927 men [11.8%]) saw a palliative care physician in the year before death, but those who did experienced greater than 50% lower odds of an end-of-life transition of care (adjusted odds ratio, 0.48; 95% CI, 0.43-0.54); P < .001) and greater than 25% lower odds of receiving antibiotics (adjusted odds ratio, 0.74; 95% CI, 0.68-0.81; P < .001). Conclusions and Relevance In this study, many nursing home residents with advanced dementia, especially men, received burdensome interventions and antibiotics in their final days of life. These findings appear to emphasize the need for sex-specific analysis in dementia research as well as the expansion of palliative care and end-of-life antimicrobial stewardship in nursing homes.
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Affiliation(s)
- Nathan M. Stall
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto, Ontario, Canada
| | | | | | - Vasily Giannakeas
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Susan E. Bronskill
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter C. Austin
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy N. Matlow
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kieran L. Quinn
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto, Ontario, Canada
| | - Susan L. Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts
| | - Chaim M. Bell
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto, Ontario, Canada
| | - Paula A. Rochon
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Abstract
In the geriatric age group, few studies demonstrate the efficacy of aggressive treatment. Often, a more palliative approach is wanted; such an approach can lead to better quality of life and even a longer life. The author discusses the limits of medical interventions in the elderly, the paucity of data, and the benefits of palliation in certain medical conditions, including dementia, Parkinson, depression, arthritis, congestive heart failure, and pneumonia. The role of frailty is addressed; specific goals of palliative care are delineated, such as reduction of polypharmacy, fall prevention, pain reduction, and the central role of a primary care provider.
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Integrating bedside nurses into antibiotic stewardship: A practical approach. Infect Control Hosp Epidemiol 2019; 40:579-584. [PMID: 30786944 DOI: 10.1017/ice.2018.362] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nurses view patient safety as an essential component of their work and have reported a general interest in embracing an antibiotic steward role. However, antibiotic stewardship (AS) functions have not been formally integrated into nursing practice despite nurses' daily involvement in clinical activities that impact antibiotic decisions (e.g., obtaining specimens for cultures, blood drawing for therapeutic drug monitoring). Recommendations to expand AS programs to include bedside nurses are generating support at a national level, yet a practical guidance on how nurses can be involved in AS activities is lacking. In this review, we provide a framework identifying selected practices where nurses can improve antibiotic prescribing practices through appropriate obtainment of Clostridioides difficile tests, appropriate urine culturing practices, optimal antibiotic administration, accurate and detailed documentation of penicillin allergy histories and through the prompting of antibiotic time outs. We identify reported barriers to engagement of nurses in AS and offer potential solutions that include patient safety principles and quality improvement strategies that can be used to mitigate participation barriers. This review will assist AS leaders interested in advancing the contributions of nurses into their AS programs by discussing education, communication, improvement models, and workflow integration enhancements that strengthen systems to support nurses as valued partners in AS efforts.
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Identifying and classifying indicators affected by performing clinical pathways in hospitals: a scoping review. INT J EVID-BASED HEA 2018; 16:3-24. [PMID: 29176429 DOI: 10.1097/xeb.0000000000000126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIM To analyse the evidence regarding indicators affected by clinical pathways (CPW) in hospitals and offer suggestions for conducting comprehensive systematic reviews. METHODS We conducted a systematic scoping review and searched the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, OVID, Science Direct, ProQuest, EMBASE and PubMed. We also reviewed the reference lists of included studies. The criteria for inclusion of studies included experimental and quasi-experimental studies, implementing CPW in secondary and tertiary hospitals and investigating at least one indicator. Quality of included studies was assessed by two authors independently using the Critical Appraisal Skills Program for clinical trials and cohort studies and the Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies. RESULTS Forty-seven out of 2191 studies met the eligibility and inclusion criteria. The majority of included studies had pretest-posttest quasi-experimental design and had been done in developed countries, especially the United States. The investigation of evidence resulted in identifying 62 indicators which were classified into three categories: input indicators, process and output indicators and outcome indicators. Outcome indicators were more frequent than other indicators. Complication rate, hospital costs and length of hospital stay were dominant in their own category. Indicators such as quality of life and adherence to guidelines have been considered in studies that were done in recent years. CONCLUSION Implementing CPW can affect different types of indicators such as input, process, output and outcome indicators, although outcome indicators capture more attention than other indicators. Patient-related indicators were dominant outcome indicators, whereas professional indicators and organizational factors were considered less extensively. WHAT IS KNOWN ABOUT THE TOPIC?: WHAT DOES THIS ARTICLE ADD?
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Leduc S, Kelly P, Thiruganasambandamoorthy V, Wells G, Vaillancourt C. The safety and efficacy of on-site paramedic and allied health treatment interventions targeting the reduction of emergency department visits by long-term care patients: systematic review protocol. Syst Rev 2018; 7:206. [PMID: 30470243 PMCID: PMC6260877 DOI: 10.1186/s13643-018-0868-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 11/01/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Older adults are more likely to access the emergency department, which suffers from overcrowding and congestion, for conditions that could potentially be treated in other settings. Older adults living in long-term care centers have access to healthcare resources in their residence, and several programs have been created with the intent of treating medical conditions on-site. The aim of this study is to identify and systematically review programs and interventions at long-term care centers that aim to treat patients on-site, avoiding unscheduled transportation to the emergency department. METHODS We will follow the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We will perform a comprehensive search of Embase, MEDLINE, CINAHL, ClinicalTrials.gov , PROSPERO, and the Cochrane Central Registry of Controlled Trials using a broad search strategy. Two independent reviewers will assess titles and abstracts against inclusion criteria, and we will further evaluate relevant full-text articles for inclusion. We will assess the risk of bias using the Newcastle-Ottawa scale for included non-randomized studies and the Cochrane Risk of Bias tool for randomized trials. We will present a narrative synthesis of results and complete a meta-analysis only if enough homogeneity is found. We will create funnel plots to evaluate possible reporting bias and use The Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology to assess the confidence in cumulative evidence. DISCUSSION As pressure on the healthcare system continues to rise, many areas are looking for alternative models of care. Several programs have been put in place in long-term care centers that seek to avoid transportation to the emergency department by providing enhanced care on-site. These programs are quite variable, and, to date, there is no standardized program or model of care. SYSTEMATIC REVIEW REGISTRATION PROSPERO ( CRD42018091636 ).
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Affiliation(s)
- Shannon Leduc
- Ottawa Paramedic Service, 2465 Don Reid Dr, Ottawa, Ontario K1H 1E2 Canada
| | - Peter Kelly
- Ottawa Paramedic Service, 2465 Don Reid Dr, Ottawa, Ontario K1H 1E2 Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa at The Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9 Canada
- Clinical Epidemiology Unit, F6 Ottawa Hospital Research Institute at The Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9 Canada
| | - George Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7 Canada
| | - Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa at The Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9 Canada
- Clinical Epidemiology Unit, F6 Ottawa Hospital Research Institute at The Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9 Canada
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Zhang Y, Diana ML. Effects of Early Dual-Eligible Special Needs Plans on Health Expenditure. Health Serv Res 2018; 53:2165-2184. [PMID: 29044547 PMCID: PMC6051974 DOI: 10.1111/1475-6773.12778] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine the effects of the penetration of dual-eligible special needs plans (D-SNPs) on health care spending. DATA SOURCES/STUDY SETTING Secondary state-level panel data from Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) public use file and Special Needs Plan Comprehensive Reports, Area Health Resource Files, and Medicaid Managed Care Enrollment Report between 2007 and 2011. STUDY DESIGN A difference-in-difference strategy that adjusts for dual-eligibles' demographic and socioeconomic characteristics, state health resources, beneficiaries' health risk factors, Medicare/Medicaid enrollment, and state- and year-fixed effects. DATA COLLECTION/EXTRACTION METHODS Data from MMLEADS were summarized from Centers for Medicare and Medicaid Services (CMS)'s Chronic Conditions Data Warehouse, which contains 100 percent of Medicare enrollment data, claims for beneficiaries who are enrolled in the fee-for-service (FFS) program, and Medicaid Analytic Extract files. The MMLEADS public use file also includes payment information for managed care. Data in Special Needs Plan Comprehensive Reports were from CMS's Health Plan Management System. PRINCIPAL FINDINGS Results indicate that D-SNPs penetration was associated with reduced Medicare spending per dual-eligible beneficiary. Specifically, a 1 percent increase in D-SNPs penetration was associated with 0.2 percent reduction in Medicare spending per beneficiary. We found no association between D-SNPs penetration and Medicaid or total spending. CONCLUSION Involving Medicaid services in D-SNPs may be crucial to improve coordination between Medicare and Medicaid programs and control Medicaid spending among dual-eligible beneficiaries. Starting from 2013, D-SNPs were mandated to have contracts with state Medicaid agencies. This change may introduce new effects of D-SNPs on health care spending. More research is needed to examine the impact of D-SNPs on dual-eligible spending.
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Affiliation(s)
- Yongkang Zhang
- Division of Health Policy and EconomicsDepartment of Healthcare Policy and ResearchWeill Cornell Medical CollegeNew YorkNY
| | - Mark L. Diana
- Department of Global Health Management and PolicySchool of Public Health and Tropical MedicineTulane UniversityNew OrleansLA
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Bartley MM, Suarez L, Shafi RMA, Baruth JM, Benarroch AJM, Lapid MI. Dementia Care at End of Life: Current Approaches. Curr Psychiatry Rep 2018; 20:50. [PMID: 29936639 DOI: 10.1007/s11920-018-0915-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Dementia is a progressive and life-limiting condition that can be described in three stages: early, middle, and late. This article reviews current literature on late-stage dementia. RECENT FINDINGS Survival times may vary across dementia subtypes. Yet, the overall trajectory is characterized by progressive decline until death. Ideally, as people with dementia approach the end of life, care should focus on comfort, dignity, and quality of life. However, barriers prevent optimal end-of-life care in the final stages of dementia. Improved and earlier advanced care planning for persons with dementia and their caregivers can help delineate goals of care and prepare for the inevitable complications of end-stage dementia. This allows for timely access to palliative and hospice care, which ultimately improves dementia end-of-life care.
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Affiliation(s)
| | - Laura Suarez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Reem M A Shafi
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Joshua M Baruth
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Amanda J M Benarroch
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Maria I Lapid
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA. .,Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: a cross-sectional analysis. Antimicrob Resist Infect Control 2018; 7:74. [PMID: 29946449 PMCID: PMC6000953 DOI: 10.1186/s13756-018-0364-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/24/2018] [Indexed: 11/10/2022] Open
Abstract
Background The pervasive, often inappropriate, use of antibiotics in healthcare settings has been identified as a major public health threat due to the resultant widespread emergence of antibiotic resistant bacteria. In nursing homes (NH), as many as two-thirds of residents receive antibiotics each year and up to 75% of these are estimated to be inappropriate. The objective of this study was to characterize antibiotic therapy for NH residents and compare appropriateness based on setting of prescription initiation. Methods This was a retrospective, cross-sectional multi-center study that occurred in five NHs in southern Wisconsin between January 2013 and September 2014. All NH residents with an antibiotic prescribing events for suspected lower respiratory tract infections (LRTI), skin and soft tissue infections (SSTI), and urinary tract infections (UTI), initiated in-facility, from an emergency department (ED), or an outpatient clinic were included in this sample. We assessed appropriateness of antibiotic prescribing using the Loeb criteria based on documentation available in the NH medical record or transfer documents. We compared appropriateness by setting and infection type using the Chi-square test and estimated associations of demographic and clinical variables with inappropriate antibiotic prescribing using logistic regression. Results Among 735 antibiotic starts, 640 (87.1%) were initiated in the NH as opposed to 61 (8.3%) in the outpatient clinic and 34 (4.6%) in the ED. Inappropriate antibiotic prescribing for urinary tract infections differed significantly by setting: NHs (55.9%), ED (73.3%), and outpatient clinic (80.8%), P = .023. Regardless of infection type, patients who had an antibiotic initiated in an outpatient clinic had 2.98 (95% CI: 1.64–5.44, P < .001) times increased odds of inappropriate use. Conclusions Antibiotics initiated out-of-facility for NH residents constitute a small but not trivial percent of all prescriptions and inappropriate use was high in these settings. Further research is needed to characterize antibiotic prescribing patterns for patients managed in these settings as this likely represents an important, yet under recognized, area of consideration in attempts to improve antibiotic stewardship in NHs.
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Measuring health related quality of life (HRQoL) in community and facility-based care settings with the interRAI assessment instruments: development of a crosswalk to HUI3. Qual Life Res 2018; 27:1295-1309. [PMID: 29435802 PMCID: PMC5891555 DOI: 10.1007/s11136-018-1800-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 11/24/2022]
Abstract
Background Health-related quality of life (HRQoL) measures are of interest because they can be used to describe health of populations and represent a broader health outcome for population health analyses than mortality rates or life expectancy. The most widely used measure of HRQoL for deriving estimates of health-adjusted life expectancy is the Health Utilities Index Mark 3 (HUI3). The HUI3 is available in most national surveys administered by Statistics Canada, and has been used as part of a microsimulation model to examine the impact of neurological conditions over the life course. Persons receiving home care and nursing home services are often not well-represented in these surveys; however, interRAI assessment instruments are now used as part of normal clinical practice in these settings for nine Canadian provinces/territories. Building on previous research that developed a HUI2 crosswalk for the interRAI assessments, the present study examined a new interRAI HRQoL index crosswalked to the HUI3. Methods interRAI and survey data were used to examine the distributional properties of global and domain-specific interRAI HRQoL and HUI3 index scores, respectively. Three populations were considered: well-elderly persons not receiving home care, home care clients and nursing home residents. Results The mean HUI3 and interRAI HRQoL index global scores declined from independent healthy older persons to home care clients, followed by nursing home residents. For the home care and nursing home populations, the interRAI HRQoL global estimates tended to be lower than HUI3 global scores obtained from survey respondents. While there were some statistically significant age, sex and diagnostic group differences in global scores and within attributes, the most notable differences were between populations from different care settings. Discussion The present study provides strong evidence for the validity of the interRAI HRQoL based on comparisons of distributional properties with those obtained with survey data based on the HUI3. The results demonstrate the importance of admission criteria for home care and nursing home settings, where function plays a more important role than demographic or diagnostic criteria. The interRAI HRQoL has a distinct advantage because it is gathered as part of normal clinical practice in care settings where interRAI instruments are mandatory and are used to assess all eligible persons in those sectors. In particular, those with severe cognitive and functional impairments (who tend to be under-represented in survey data) will be evaluated using the interRAI tools. Future research should build on this work by providing direct, person-level comparisons of interRAI HRQoL index and HUI3 scores, as well as longitudinal analyses to examine responsiveness to change.
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Mohamed WRA, Leach MJ, Reda NA, Abd-Ellatif MM, Mohammed MA, Abd-Elaziz MA. The effectiveness of clinical pathway-directed care on hospitalisation-related outcomes in patients with severe traumatic brain injury: A quasi-experimental study. J Clin Nurs 2018; 27:e820-e832. [PMID: 29193516 DOI: 10.1111/jocn.14194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 12/14/2022]
Abstract
AIMS AND OBJECTIVES To compare the effectiveness of clinical pathway-directed care to usual care on hospitalisation-related outcomes in patients with severe traumatic brain injury (STBI). BACKGROUND Severe traumatic brain injury is a major cause of disability and mortality in young adults. Clinical pathways endeavour to bring evidence and clinical practice closer together to foster the delivery of best practice and to improve patient outcomes. DESIGN Quasi-experimental study. METHODS The study was conducted in a trauma intensive care unit of a large teaching hospital in Egypt. Patients aged 18-60 years with a diagnosis of STBI, a Glasgow Coma Scale score between 3-8 and a nonpenetrating head injury were consecutively assigned to 15 days of care. The outcomes assessed were complications related to hospitalisation, clinical variances, length of intensive care unit (ICU) stay, ICU readmission rate and patient/family satisfaction. RESULTS Sixty participants completed the study (30 in each arm). Apart from age, there were no significant differences between groups in baseline characteristics. The clinical pathway group demonstrated statistically significantly fewer cases of hospitalisation-related complications on day 15, and a significantly shorter length of ICU stay, lower ICU readmission rate and a high level of patient/family satisfaction when compared with the usual care group. The effect of the intervention on fever, pressure ulceration, hyperglycaemia and readmission to the ICU was no longer statistically significant after controlling for age. CONCLUSIONS The findings of the current study suggest that the implementation of a clinical pathway for patients with severe TBI may be helpful in improving the patient experience as well as some hospitalisation-related outcomes. RELEVANCE TO CLINICAL PRACTICE The provision of clinical pathway-directed care in a trauma ICU may offer benefits to the patient, family and institution beyond that provided by usual care.
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Affiliation(s)
| | - Matthew J Leach
- Department of Rural Health, University of South Australia, Adelaide, SA, Australia
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Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial. Med Care 2017; 56:11-18. [PMID: 29068904 DOI: 10.1097/mlr.0000000000000835] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested. OBJECTIVE Test the impact of PCTeams on end-of-life outcomes. RESEARCH DESIGN Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect. SUBJECTS In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents). MEASURES Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions. RESULTS Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations. CONCLUSIONS The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.
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Abstract
The incidence of pneumonia increases with age, and is particularly high in patients who reside in long-term care facilities (LTCFs). Mortality rates for pneumonia in older adults are high and have not decreased in the last decade. Atypical symptoms and exacerbation of underlying illnesses should trigger clinical suspicion of pneumonia. Risk factors for multidrug-resistant organisms are more common in older adults, particularly among LTCF residents, and should be considered when making empiric treatment decisions. Monitoring of clinical stability and underlying comorbid conditions, potential drug-drug interactions, and drug-related adverse events are important factors in managing elderly patients with pneumonia.
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Affiliation(s)
- Oryan Henig
- Division of Infectious Diseases, Department of Medicine, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109-5680, USA
| | - Keith S Kaye
- Division of Infectious Diseases, Department of Medicine, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109-5680, USA.
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Romøren M, Gjelstad S, Lindbæk M. A structured training program for health workers in intravenous treatment with fluids and antibiotics in nursing homes: A modified stepped-wedge cluster-randomised trial to reduce hospital admissions. PLoS One 2017; 12:e0182619. [PMID: 28880941 PMCID: PMC5589147 DOI: 10.1371/journal.pone.0182619] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 07/19/2017] [Indexed: 11/22/2022] Open
Abstract
Objectives Hospitalization is potentially detrimental to nursing home patients and resource demanding for the specialist health care. This study assessed if a brief training program in administrating intravenous fluids and antibiotics in nursing homes could reduce hospital transfers and ensure high quality care locally. Design A pragmatic and modified cluster randomized stepped-wedge trial with randomization on nursing home level. Participants 330 cases in 296 nursing home residents from 30 nursing homes were included. Cases were patients provided intravenous antibiotics or intravenous fluids, in nursing home or hospital. Primary outcome was localization of treatment, secondary outcomes were number of days treated, days of hospitalization among admitted patients, type of antibiotics used and 30-day mortality. Intervention The nursing homes sequentially received a one-day educational program for the health workers including theory and practical training in intravenous treatment of dehydration and infection, run by two skilled nurses. After completing the training program, the nursing homes had competence to provide intravenous treatment locally. Results The intervention had a highly significant effect on treatment in nursing homes (OR 8.35, 2.08 to 33.6; P<0.01, or RR 2.23, 1.48 to 2.56). The number treated in nursing homes was stable over time; the number treated in hospital gradually decreased (chi square for trend P< 0.001). Among patients receiving intravenous antibiotics in the nursing homes, 50 (46%) died within 30 days, compared to 30 (36%) treated in the hospital (P = 0.19). Among patients receiving intravenous fluids locally, 21 (19%) died within 30 days, compared to 2 (8%) in the hospital group (P = 0.34). Mortality was associated with reduced consciousness and elevated c-reactive protein. Conclusions A brief educational program delivered to nursing home personnel was feasible and effective in reducing acute hospital admissions from nursing homes for treatment of dehydration and infections.
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Affiliation(s)
- Maria Romøren
- Department of Administration Vestfold Hospital Trust, Tønsberg, Norway
- Department of General Practice Institute of Health and Society, University of Oslo, Blindern, Oslo, Norway
- * E-mail:
| | - Svein Gjelstad
- Department of General Practice Institute of Health and Society, University of Oslo, Blindern, Oslo, Norway
| | - Morten Lindbæk
- Department of General Practice Institute of Health and Society, University of Oslo, Blindern, Oslo, Norway
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Miller SC, Lima JC, Intrator O, Martin E, Bull J, Hanson LC. Specialty Palliative Care Consultations for Nursing Home Residents With Dementia. J Pain Symptom Manage 2017; 54:9-16.e5. [PMID: 28438589 PMCID: PMC5663286 DOI: 10.1016/j.jpainsymman.2017.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/20/2017] [Accepted: 03/17/2017] [Indexed: 12/22/2022]
Abstract
CONTEXT U.S. nursing home (NH) residents with dementia have limited access to specialty palliative care beyond Medicare hospice. OBJECTIVES The objective of this study was to examine the value of expanded palliative care access for NH residents with moderate-to-very severe dementia. METHODS We merged palliative care consultation data in 31 NHs in two states to Medicare data to identify residents with consultations, moderate-to-very severe dementia, and deaths in 2006-2010. Initial palliative consultations were identified as occurring later and earlier (1-30 days and 31-180 days before death, respectively). Three controls for each consultation recipient were selected using propensity score matching. Weighted multivariate analyses evaluated the effect of consultations on hospital or acute care use seven and 30 days before death and on (potentially) burdensome transitions (i.e., hospital or hospice admission three days before death or two plus acute care transitions 30 days before death). RESULTS With earlier consultation (vs. no consultation), hospitalization rates in the seven days before death were on average 13.2 percentage points lower (95% confidence interval [CI] -21.8%, -4.7%) and with later consultation 5.9 percentage points lower (95% CI -13.7%, +4.9%). For earlier consultations (vs. no consultations), rates were 18.4 percentage points lower (95% CI -28.5%, -8.4%) for hospitalizations and 11.9 lower (95% CI -20.7%, -3.1%) for emergency room visits 30 days before death; they were 20.2 percentage points lower (95% CI -28.5%, -12.0%) for burdensome transitions. CONCLUSION Consultations appear to reduce acute care use and (potentially) burdensome transitions for dying residents with dementia. Reductions were greater when consultations were earlier.
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Affiliation(s)
- Susan C Miller
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA; Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA.
| | - Julie C Lima
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA; Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA; Geriatrics and Extended Care Data and Analyses Center, Canandaigua Veterans Administration Medical Center, Canandaigua, New York, USA
| | - Edward Martin
- Department of Medicine, Brown University, Providence, Rhode Island, USA; Hope Hospice and Palliative Care, Providence, Rhode Island, USA
| | - Janet Bull
- Four Seasons, Flat Rock, North Carolina, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Center for Aging and Health, Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina, USA
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Ma J, Yan HY, Yang YH. Clinical effects of clinical nursing pathway for acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2017; 25:816-821. [DOI: 10.11569/wcjd.v25.i9.816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effect of clinical nursing pathway for acute pancreatitis (AP).
METHODS One hundred and sixty patients with AP treated at our hospital from January 2015 to December 2016 were enrolled in this study. The patients were randomly divided into either an observation group or a control group, with 80 cases in each group. Clinical nursing pathway was used in the observation group, while conventional nursing care was used in the control group. Clinical symptoms, length of hospital stay, and adverse effects were compared between the two groups.
RESULTS The duration of stomach ache and abdominal distention was significantly shorter in the observation group than in the control group (6.02 d ± 4.23 d vs 8.56 d ± 5.33 d, t = 3.308, P = 0.001; 6.78 d ± 4.21 d vs 9.67 d ± 5.92 d, t = 3.558, P < 0.001). The length of hospital stay was significantly shorter in the observation group than in the control group (27.50 d ± 9.32 d vs 34.45 d ± 12.72 d, t = 3.942, P < 0.001). The rate of adverse effects such as esophageal mucosal injury, lower limb vein thrombosis, and lung infection was significantly lower in the observation group than in the control group.
CONCLUSION Clinical nursing pathway can promote the rehabilitation of AP and reduce adverse effect and negative emotion.
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Kjelle E, Lysdahl KB. Mobile radiography services in nursing homes: a systematic review of residents' and societal outcomes. BMC Health Serv Res 2017; 17:231. [PMID: 28335759 PMCID: PMC5364720 DOI: 10.1186/s12913-017-2173-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 03/18/2017] [Indexed: 11/23/2022] Open
Abstract
Background Demographic changes are leading to an ageing population in Europe, and predict an increase in the number of nursing home residents over the next 30 years. Nursing home residents need specialised healthcare services such as radiology due to both chronic and acute illnesses. Mobile radiography, x-ray examinations performed in the nursing homes, may be a good way of providing services to this population. The aim of this systematic review was to identify the outcomes of mobile radiography services for nursing home residents and society. Methods A systematic review based on searches in the Medline, Cochrane, PubMed, Embase and Svemed + databases was performed. Titles and abstracts were screened according to a predefined set of inclusion criteria: empirical studies in the geriatric population, and reports of mobile radiography services in a clinical setting. All publications were quality appraised using MMAT or CASP appraisal tools. Data were extracted using a summary table and results were narratively synthesised. Results Ten publications were included. Three overarching outcomes were identified: 1) reduced number of hospitalisations and outpatient examinations or treatments, 2) reduced number of transfers between nursing homes and hospitals and 3) increased access to x-ray examinations. These outcomes were interlinked with the more specific outcomes for residents and society reported in the literature. For residents there was a reduction in burdensome transfers and waiting time and adequate treatment and care increased. For society, released resources could be used more efficiently, and overall costs were reduced substantially. Conclusions This review indicates that mobile radiography services for nursing home residents in the western world are of comparable quality to hospital-based examinations and have clear potential benefits. Mobile radiography reduced transfers to and from hospital, increased the number of examinations carried out and facilitated timely diagnosis and access to treatments. Further research is needed to formally evaluate potential improvements in care quality and cost-effectiveness. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2173-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elin Kjelle
- Department of Optometry, Radiography and Lighting Design, Faculty of Health and Social Sciences, University College of Southeast Norway, Postboks 235, 3603, Kongsberg, Norway.
| | - Kristin Bakke Lysdahl
- Institute of radiography and dental technology, Department of Life Sciences and Health, Faculty of health sciences, Oslo and Akershus University College of Applied Sciences, Postboks 4, St. Olavs plass, 0130, Oslo, Norway
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Martin RS, Hayes BJ, Hutchinson A, Yates P, Lim WK. Implementation of 'Goals of Patient Care' medical treatment orders in residential aged care facilities: protocol for a randomised controlled trial. BMJ Open 2017; 7:e013909. [PMID: 28283490 PMCID: PMC5353337 DOI: 10.1136/bmjopen-2016-013909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Systematic reviews demonstrate that advance care planning (ACP) has many positive effects for residents of aged care facilities, including decreased hospitalisation. The proposed Residential Aged Care Facility (RACF) 'Goals of Patient Care' (GOPC) form incorporates a resident's prior advance care plan into medical treatment orders. Where none exists, it captures residents' preferences. This documentation helps guide healthcare decisions made at times of acute clinical deterioration. METHODS AND ANALYSIS This is a mixed methods study. An unblinded cluster randomised controlled trial is proposed in three pairs of RACFs. In the intervention arm, GOPC forms will be completed by a doctor incorporating advance care plans or wishes. In the control arm, residents will have usual care which may include an advance care plan. The primary hypothesis is that the GOPC form is superior to standard ACP alone and will lead to decreased hospitalisation due to clearer documentation of residents' medical treatment plans. The primary outcome will be an analysis of the effect of the GOPC medical treatment orders on emergency department attendances and hospital admissions at 6 months. Secondary outcome measurements will include change in hospitalisation rates at 3 and 12 months, length of stay and external mortality rates among others. Qualitative interviews, 12 months post GOPC implementation, will be used for process evaluation of the GOPC and to evaluate staff perceptions of the form's usefulness for improving communication and medical decision-making at a time of deterioration. DISSEMINATION The results will be disseminated in peer review journals and research conferences. This robust randomised controlled trial will provide high-quality data about the influence of medical treatment orders that incorporate ACP or preferences adding to the current gap in knowledge and evidence in this area. TRIAL REGISTRATION NUMBER ACTRN12615000298516, Results.
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Affiliation(s)
- Ruth S Martin
- Northern Health, Epping, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | | | - Anastasia Hutchinson
- Northern Health, Epping, Victoria, Australia
- Deakin University, Geelong, Victoria, Australia
| | - Paul Yates
- University of Melbourne, Melbourne, Victoria, Australia
- Austin Health, Heidelberg, Victoria, Australia
| | - Wen Kwang Lim
- Northern Health, Epping, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Health, Melbourne, Victoria, Australia
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Mauritzon IC, Blom M, Borna C, Ivarsson K. Attending physicians believe that hospitalized patients are treated at the appropriate level of care: A qualitative study. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2016. [DOI: 10.1179/2047971915y.0000000021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Xing J, Mukamel DB, Glance LG, Zhang N, Temkin-Greener H. Medicaid Reimbursement and the Quality of Nursing Home Care: A Case Study of Medi-Cal Long-Term Care Reimbursement Act of 2004 in California. WORLD MEDICAL & HEALTH POLICY 2016. [DOI: 10.1002/wmh3.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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