1
|
Li W, Manuel DG, Isenberg SR, Tanuseputro P. Using Exploratory Structural Equation Modeling to Examine Caregiver Distress and Its Contributors. J Am Med Dir Assoc 2024; 25:817-825.e5. [PMID: 38341185 DOI: 10.1016/j.jamda.2023.12.019] [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: 08/30/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 02/12/2024]
Abstract
OBJECTIVES To develop and test the direct and indirect associations between caregiver distress and its many contributing factors and covariates. DESIGN Analysis using data from a national, cross-sectional survey of Canadian caregivers. SETTING AND PARTICIPANTS A total of 6502 respondents of the 2012 General Social Survey-Caregiving and Care-receiving who self-identified as a caregiver. METHODS We used exploratory structural equation modeling to achieve our aims. Based on literature review, we hypothesized a structural model of 5 caregiving factors that contribute to distress: caregiving burden, caregiving network and support, disruptions of family and social life, positive emotional experiences, and caregiving history. Survey items hypothesized to measure each latent factor were modeled using exploratory factor analysis (EFA). After establishing a well-fit EFA model, structural equation modeling was performed to examine the relationships between caregiving factors and caregiver distress while controlling for covariates such as caregiver's and care-recipient's sociodemographic characteristics and kinship. RESULTS EFA established a well-fit model that represented caregiver distress and its 5 contributing factors as hypothesized. Although all 5 had significant effects on caregiver distress, disruptions of family and social life contributed the most (β = 0.462), almost 3 times that of caregiving burden (β = 0.162). Positive emotional experiences also substantially reduced distress (β = -0.310). CONCLUSIONS AND IMPLICATIONS Understanding the multifaceted nature of caregiver distress is crucial for developing effective strategies to support caregivers. In addition to reducing caregiving burden, having flexible resources and policies to minimize disruptions to caregivers' families (eg, flexible work policies; family-oriented education, training, and counseling) and enhance the positive aspects of caregiving may more effectively reduce distress.
Collapse
Affiliation(s)
- Wenshan Li
- Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada.
| | - Douglas G Manuel
- Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- ICES uOttawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
2
|
Arsenault-Lapierre G, Bui T, Godard-Sebillotte C, Kang N, Sourial N, Rochette L, Massamba V, Quesnel-Vallée A, Vedel I. Sex Differences in Healthcare Utilization in Persons Living with Dementia Between 2000 and 2017: A Population-Based Study in Quebec, Canada. J Aging Health 2024:8982643241242512. [PMID: 38554023 DOI: 10.1177/08982643241242512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2024]
Abstract
Objectives: Describe sex differences in healthcare utilization and mortality in persons with new dementia in Quebec, Canada. Methods: We conducted a repeated cohort study from 2000 to 2017 using health administrative databases. Community-dwelling persons aged 65+ with a new diagnosis of dementia were included. We measured 23 indicators of healthcare use across five care settings: ambulatory care, pharmacological care, acute hospital care, long-term care, and mortality. Clinically meaningful sex differences in age-standardized rates were determined graphically through expert consultations. Results: Women with dementia had higher rates of ambulatory care and pharmacological care, while men with dementia had higher acute hospital care, admission to long-term care, and mortality. There was no meaningful difference in visits to cognition specialists, antipsychotic prescriptions, and hospital death. Discussion: Men and women with dementia demonstrate differences in healthcare utilization and mortality. Addressing these differences will inform decision-makers, care providers and researchers and guide more equitable policy and interventions in dementia care.
Collapse
Affiliation(s)
- Genevieve Arsenault-Lapierre
- Center for Research and Expertise in Social Gerontology, Centre Intégré Universitaire de Santé et Services Sociaux Du Centre-Ouest de l'Ile de Montréal, Montreal, QC, Canada
| | - Tammy Bui
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Claire Godard-Sebillotte
- McGill University Health Centre Research Institute, Montreal, QC, Canada
- Department of Medicine Division of Geriatrics, McGill University, Montreal, QC, Canada
| | - Nia Kang
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Nadia Sourial
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montreal, Montreal, QC, Canada
- Research Center of the Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Louis Rochette
- Institut National de Santé Publique Du Québec, Montreal, QC, Canada
| | | | - Amélie Quesnel-Vallée
- Department of Equity, Ethics, and Policy, School of Population and Global Health, McGill University, Montreal, QC, Canada
- Department of Sociology, McGill University, Montreal, QC, Canada
| | - Isabelle Vedel
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| |
Collapse
|
3
|
Bonares M, Fisher S, Quinn K, Wentlandt K, Tanuseputro P. Study protocol for the development and validation of a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. Diagn Progn Res 2024; 8:5. [PMID: 38500236 PMCID: PMC10949607 DOI: 10.1186/s41512-024-00168-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/05/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Patients with dementia and their caregivers could benefit from advance care planning though may not be having these discussions in a timely manner or at all. A prognostic tool could serve as a prompt to healthcare providers to initiate advance care planning among patients and their caregivers, which could increase the receipt of care that is concordant with their goals. Existing prognostic tools have limitations. We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. METHODS The derivation cohort will include approximately 235,000 patients with dementia, who were admitted to hospital in Ontario from April 1st, 2009, to December 31st, 2017. Predictor variables will be fully prespecified based on a literature review of etiological studies and existing prognostic tools, and on subject-matter expertise; they will be categorized as follows: sociodemographic factors, comorbidities, previous interventions, functional status, nutritional status, admission information, previous health care utilization. Data-driven selection of predictors will be avoided. Continuous predictors will be modelled as restricted cubic splines. The outcome variable will be mortality within 1 year of admission, which will be modelled as a binary variable, such that a logistic regression model will be estimated. Predictor and outcome variables will be derived from linked population-level healthcare administrative databases. The validation cohort will comprise about 63,000 dementia patients, who were admitted to hospital in Ontario from January 1st, 2018, to March 31st, 2019. Model performance, measured by predictive accuracy, discrimination, and calibration, will be assessed using internal (temporal) validation. Calibration will be evaluated in the total validation cohort and in subgroups of importance to clinicians and policymakers. The final model will be based on the full cohort. DISCUSSION We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. The model would be integrated into the electronic medical records of hospitals to automatically output 1-year mortality risk upon hospitalization. The tool could serve as a trigger for advance care planning and inform access to specialist palliative care services with prognosis-based eligibility criteria. Before implementation, the tool will require external validation and study of its potential impact on clinical decision-making and patient outcomes. TRIAL REGISTRATION NCT05371782.
Collapse
Affiliation(s)
- Michael Bonares
- Department of Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Stacey Fisher
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- ICES Ottawa, Ottawa, ON, Canada
| | - Kieran Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
- ICES Toronto, Toronto, ON, Canada
| | - Kirsten Wentlandt
- Department of Supportive Care, University Health Network, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- ICES Ottawa, Ottawa, ON, Canada
| |
Collapse
|
4
|
Bocquier A, Erkilic B, Babinet M, Pulcini C, Agrinier N. Resident-, prescriber-, and facility-level factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies. Antimicrob Resist Infect Control 2024; 13:29. [PMID: 38448955 PMCID: PMC10918961 DOI: 10.1186/s13756-024-01385-6] [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: 10/26/2023] [Accepted: 02/29/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programmes are needed in long-term care facilities (LTCFs) to tackle antimicrobial resistance. We aimed to identify factors associated with antibiotic use in LTCFs. Such information would be useful to guide antimicrobial stewardship programmes. METHOD We conducted a systematic review of studies retrieved from PubMed, Cochrane Library, Embase, APA PsycArticles, APA PsycINFO, APA PsycTherapy, ScienceDirect and Web of Science. We included quantitative studies that investigated factors associated with antibiotic use (i.e., antibiotic prescribing by health professionals, administration by LTCF staff, or use by residents). Participants were LTCF residents, their family, and/or carers. We performed a qualitative narrative synthesis of the findings. RESULTS Of the 7,591 screened records, we included 57 articles. Most studies used a longitudinal design (n = 34/57), investigated resident-level (n = 29/57) and/or facility-level factors (n = 32/57), and fewer prescriber-level ones (n = 8/57). Studies included two types of outcome: overall volume of antibiotic prescriptions (n = 45/57), inappropriate antibiotic prescription (n = 10/57); two included both types. Resident-level factors associated with a higher volume of antibiotic prescriptions included comorbidities (5 out of 8 studies which investigated this factor found a statistically significant association), history of infection (n = 5/6), potential signs of infection (e.g., fever, n = 4/6), positive urine culture/dipstick results (n = 3/4), indwelling urinary catheter (n = 12/14), and resident/family request for antibiotics (n = 1/1). At the facility-level, the volume of antibiotic prescriptions was positively associated with staff turnover (n = 1/1) and prevalence of after-hours medical practitioner visits (n = 1/1), and negatively associated with LTCF hiring an on-site coordinating physician (n = 1/1). At the prescriber-level, higher antibiotic prescribing was associated with high prescription rate for antibiotics in the previous year (n = 1/1). CONCLUSIONS Improving infection prevention and control, and diagnostic practices as part of antimicrobial stewardship programmes remain critical steps to reduce antibiotic prescribing in LTCFs. Once results confirmed by further studies, implementing institutional changes to limit staff turnover, ensure the presence of a professional accountable for the antimicrobial stewardship activities, and improve collaboration between LTCFs and external prescribers may contribute to reduce antibiotic prescribing.
Collapse
Affiliation(s)
- Aurélie Bocquier
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France.
| | - Berkehan Erkilic
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
| | - Martin Babinet
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, F-54000, France
| | - Céline Pulcini
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
- Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, F-54000, France
| | - Nelly Agrinier
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, F-54000, France
| |
Collapse
|
5
|
Zhang Y, Luth EA, Phongtankuel V, Ling W, Zhang M, Shao H. Factors associated with preventable hospitalizations after hospice live discharge among Medicare patients with Alzheimer's disease and related dementias. J Am Geriatr Soc 2023; 71:3631-3635. [PMID: 37417691 PMCID: PMC10771532 DOI: 10.1111/jgs.18505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/09/2023] [Accepted: 06/24/2023] [Indexed: 07/08/2023]
Affiliation(s)
- Yongkang Zhang
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, NY, USA
| | - Elizabeth A. Luth
- Institute for Health, Healthcare Policy and Aging Research, Department of Family Medicine and Community Health, Rutgers University, New Brunswick, NJ, USA
| | - Veerawat Phongtankuel
- Division of Geriatrics and Palliative Medicine, New York-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Wodan Ling
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, NY, USA
| | - Manyao Zhang
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, NY, USA
| | - Hui Shao
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| |
Collapse
|
6
|
Gitau K, Huang A, Isenberg SR, Stall N, Ailon J, Bell CM, Quinn KL. Association of patient sex with use of palliative care in Ontario, Canada: a population-based study. CMAJ Open 2023; 11:E1025-E1032. [PMID: 37935486 PMCID: PMC10635704 DOI: 10.9778/cmajo.20220232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND It is unclear whether there are sex-based differences in use of palliative care near the end of life. The objective of this study was to measure the association between sex and palliative care use. METHODS We performed a population-based retrospective cohort study of all patients aged 18 years or older in the last year of life who died in Ontario, Canada, between 2010 and 2018. The primary exposure was patient biologic sex (male or female). The primary outcome was receipt of physician-delivered palliative care; secondary outcomes were approach to in-hospital palliative care and sex concordance of the patient and referring physician. We used multivariable modified Poisson regression to measure the association between patient sex and palliative care receipt, as well as patient-physician sex concordance. RESULTS There were 706 722 patients (354 657 females [50.2%], median age 80 yr [interquartile range 69-87 yr]) in the study cohort, 377 498 (53.4%) of whom received physician-delivered palliative care. After adjustment for age and selected comorbidities, female sex was associated with a 9% relative increase (adjusted relative risk [RR] 1.09, 95% CI 1.08-1.10) in receipt of physician-delivered palliative care. Female patients were 16% more likely than male patients (adjusted RR 1.14, 95% CI 1.14-1.18) to have had their first hospital admission in their final year of life categorized as having a likely palliative intent. Female patients were 18% more likely than male patients (RR 1.18, 95% CI 1.17-1.19) to have had a female referring physician, and male patients were 20% more likely than female patients (adjusted RR 1.20, CI 1.19-1.21) to have had a male referring physician. INTERPRETATION After adjustment for age and comorbidities, male patients were slightly less likely than female patients to have received physician-delivered palliative care, and female patients were more likely than male patients to have had their first hospital admission in their final year of life categorized as having a likely palliative care intent. These results may reflect a between-sex difference in overall end-of-life care preferences or sex differences in decision-making influenced by patient-specific factors; further studies exploring how these factors affect end-of-life decision-making are required.
Collapse
Affiliation(s)
- Kevin Gitau
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Anjie Huang
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Sarina R Isenberg
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Nathan Stall
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Jonathan Ailon
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Chaim M Bell
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Kieran L Quinn
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.
| |
Collapse
|
7
|
Fassmer AM, Allers K, Helbach J, Zuidema S, Freitag M, Zieschang T, Hoffmann F. Hospitalization of German and Dutch Nursing Home Residents Depend on Different Long-Term Care Structures: A Systematic Review on Periods of Increased Vulnerability. J Am Med Dir Assoc 2023; 24:609-618.e6. [PMID: 36898411 DOI: 10.1016/j.jamda.2023.01.030] [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: 11/15/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVE To investigate proportions of hospitalized nursing home residents during periods of increased vulnerability, ie, the first 6 months after institutionalization and the last 6 months before death, and comparing the figures between Germany and the Netherlands. DESIGN Systematic review, registered in PROSPERO (CRD42022312506). SETTING AND PARTICIPANTS Newly admitted or deceased residents. METHODS We searched MEDLINE via PubMed, EMBASE, and CINAHL from inception through May 3, 2022. We included all observational studies that reported the proportions of all-cause hospitalizations among German or Dutch nursing home residents during these defined vulnerable periods. Study quality was assessed using the Joanna Briggs Institute's tool. We assessed study and resident characteristics and outcome information and descriptively reported them separately for both countries. RESULTS We screened 1856 records for eligibility and included 9 studies published in 14 articles (Germany: 8; Netherlands: 6). One study for each country investigated the first 6 months after institutionalization. A total of 10.2% of the Dutch and 42.0% of the German nursing home residents were hospitalized during this time. Overall, 7 studies reported on in-hospital deaths, with proportions ranging from 28.9% to 29.5% for Germany and from 1.0% to 16.3% for the Netherlands. Proportions for hospitalization in the last 30 days of life ranged from 8.0% to 15.7% (Netherlands: n = 2) and from 48.6% to 58.0% (Germany: n = 3). Only German studies assessed the differences by age and sex. Although hospitalizations were less common at older ages, they were more frequent in male residents. CONCLUSIONS AND IMPLICATIONS During the observed periods, the proportion of nursing homes residents being hospitalized differed greatly between Germany and the Netherlands. The higher figures for Germany can probably be explained by differences in the long-term care systems. There is a lack of research, especially for the first months after institutionalization, and future studies should examine the care processes of nursing home residents following acute events in more detail.
Collapse
Affiliation(s)
- Alexander M Fassmer
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany.
| | - Katharina Allers
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Jasmin Helbach
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Sytse Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michael Freitag
- Division of General Practice, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Tania Zieschang
- Division of Geriatrics, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Falk Hoffmann
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| |
Collapse
|
8
|
Chen JTC, Austin PC, Luo J, Campitelli MA, Bronskill SE, Yu C, Rochon PA, Lipscombe LL, Lega IC. Patterns of diabetes testing for older adults without diabetes in Ontario's nursing homes: A population-based study. J Am Geriatr Soc 2023; 71:720-729. [PMID: 36515210 DOI: 10.1111/jgs.18152] [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: 09/13/2022] [Revised: 10/31/2022] [Accepted: 11/06/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Asymptomatic diabetes testing may be of limited value for older nursing home residents, but most diabetes guidelines lack upper-age cutoffs for screening cessation. We evaluated patterns of glycated hemoglobin (HbA1c) and serum blood glucose (SBG) testing among older residents without diabetes in Ontario, Canada. METHODS This population-based retrospective cohort study used provincial health administrative data from ICES to identify older nursing home residents in Ontario without diabetes between January 1, 2015 and December 31, 2018. We examined HbA1c and glucose testing rates overall, by age, sex, and near end-of-life. The number of tests needed to identify one case of diabetes (using HbA1c thresholds of 6.5% and 8.0%) were also calculated. RESULTS Among 102,923 older nursing home residents (70.3% women; average age 85.6 ± SD 7.7 years), 46.1% of residents received ≥1 HbA1c test over an average follow-up period of 2.15 (± SD 1.49) years, and 18.2% of these tested residents received ≥4 HbA1c tests. The crude HbA1c testing rate was 52.6 tests/100 person-years (95% CI 52.3-52.9). Testing rates among residents aged ≥80 years was 50.7 HbA1c tests/100 person-years (95% CI 50.4-51.0), and 47.8 tests/100 person-years (95% CI 46.5-49.0) among residents near end-of-life. The number of tests to identify a case of diabetes (HbA1c ≥ 6.5%) was 44, while the number of tests to identify a case of actionable diabetes (HbA1c ≥ 8%) was 310. Less than 1% of residents with an HbA1c test met criteria for actionable diabetes. CONCLUSIONS Nursing home residents without diabetes receive frequent diabetes testing, with high testing rates even in residents over 80 years old and residents near end-of-life. The high number of tests needed to identify a case of actionable diabetes highlights the urgent need to re-evaluate diabetes testing practices in nursing homes.
Collapse
Affiliation(s)
- Jim T C Chen
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | | | | | - Susan E Bronskill
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Catherine Yu
- Department of Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Lorraine L Lipscombe
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Iliana C Lega
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| |
Collapse
|
9
|
Sex-Related Differences in Acuity and Postoperative Complications, Mortality and Failure to Rescue. J Surg Res 2023; 282:34-46. [PMID: 36244225 PMCID: PMC10024256 DOI: 10.1016/j.jss.2022.09.012] [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: 03/03/2022] [Revised: 08/16/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Yentl syndrome describing sex-related disparities has been extensively studied in medical conditions but not after surgery. This retrospective cohort study assessed the association of sex, frailty, presenting with preoperative acute serious conditions (PASC), and the expanded Operative Stress Score (OSS) with postoperative complications, mortality, and failure-to-rescue. METHODS The National Surgical Quality Improvement Program from 2015 to 2019 evaluating 30-d complications, mortality, and failure-to-rescue. RESULTS Of 4,860,308 cases (43% were male; mean [standard deviation] age of 56 [17] y), 6.0 and 0.8% were frail and very frail, respectively. Frailty score distribution was higher in men versus women (P < 0.001). Most cases were low-stress OSS2 (44.9%) or moderate-stress OSS3 (44.5%) surgeries. While unadjusted 30-d mortality rates were higher (P < 0.001) in males (1.1%) versus females (0.8%), males had lower odds of mortality (adjusted odds ratio (aOR) = 0.92, 95% confidence interval [CI] = 0.90-0.94, P < 0.001) after adjusting for frailty, OSS, case status, PASC, and Clavien-Dindo IV (CDIV) complications. Males have higher odds of PASC (aOR = 1.33, CI = 1.31-1.35, P < 0.001) and CDIV complications (aOR = 1.13, CI = 1.12-1.15, P < 0.001). Male-PASC (aOR = 0.76, CI = 0.72-0.80, P < 0.001) and male-CDIV (aOR = 0.87, CI = 0.83-0.91, P < 0.001) interaction terms demonstrated that the increased odds of mortality associated with PASC or CDIV complications/failure-to-rescue were lower in males versus females. CONCLUSIONS Our study provides a comprehensive analysis of sex-related surgical outcomes across a wide range of procedures and health care systems. Females presenting with PASC or experiencing CDIV complications had higher odds of mortality/failure to rescue suggesting sex-related care differences. Yentl syndrome may be present in surgical patients; possibly related to differences in presenting symptoms, patient care preferences, or less aggressive care in female patients and deserves further study.
Collapse
|
10
|
Davies I, Meystre C, Dale J. Do Healthy People Engage With Education About Death, Dying and Advance Care Planning? An Early Evaluation of the Omega Course. Am J Hosp Palliat Care 2023; 40:67-73. [PMID: 36270635 DOI: 10.1177/10499091221116794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Death can be difficult to address personally, to discuss and to plan for. Since 2016 The Omega Course (Omega) has educated local people in Kenilworth, UK, about death and dying; broaching these issues and teaching communication skills whilst enabling social interaction. It aspires to produce practical outcomes with positive implications for end of life (EoL) planning and future neighbourhood care within the town. Aim: To investigate the impact of Omega on the attitudes and actions of participants. Method: Anonymous questionnaires, distributed by Qualtrics, or by post if preferred, were sent to 62 participants of Omega aged 22-94 two and a half years post course institution. Thematic analysis and inferential statistics were used. Results: 23 replies (37%) scored changes across 4 areas; barriers to discussion, ease discussing death, fears about death and future planning capability. All showed a significant beneficial change using a Paired Sample t-test (P< .01). Respondents noted common fears of death and dying, barriers to discussing the topic and planning for it. The course helped to allay fear, enabled discussion and encouraged planning for death and EoL. Respondents rated the course as 9.1/10 for achieving its aims. They appreciated discussing death and dying in a supportive environment and found the approach effective in developing their skills and changing attitudes. Conclusion: Omega has the potential to change attitudes towards death; promoting discussion, planning, and tackling misconceptions.
Collapse
|
11
|
Schnakenberg R, Fassmer AM, Allers K, Hoffmann F. Characteristics and place of death in home care recipients in Germany - an analysis of nationwide health insurance claims data. BMC Palliat Care 2022; 21:172. [PMID: 36203168 PMCID: PMC9535886 DOI: 10.1186/s12904-022-01060-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 09/22/2022] [Indexed: 11/27/2022] Open
Abstract
Background Most care-dependent people live at home, where they also would prefer to die. Unfortunately, this wish is often not fulfilled. This study aims to investigate place of death of home care recipients, taking characteristics and changes in care settings into account. Methods We retrospectively analysed a cohort of all home-care receiving people of a German statutory health insurance who were at least 65 years and who deceased between January 2016 and June 2019. Next to the care need, duration of care, age, sex, and disease, care setting at death and place of death were considered. We examined the characteristics by place of care, the proportion of dying in hospital by care setting and characterised the deceased cohort stratified by their actual place of death. Results Of 46,207 care-dependent people initially receiving home care, 57.5% died within 3.5 years (n = 26,590; mean age: 86.8; 66.6% female). More than half of those moved to another care setting before death with long-term nursing home care (32.3%) and short-term nursing home care (11.7%) being the most frequent transitions, while 48.1% were still cared for at home. Overall, 36.9% died in hospital and in-hospital deaths were found most often in those still receiving home care (44.7%) as well as care in semi-residential arrangements (43.9%) at the time of death. People who died in hospital were younger (mean age: 85.5 years) and with lower care dependency (low care need: 28.2%) as in all other analysed care settings. Conclusion In Germany, changes in care settings before death occur often. The proportion of in-hospital death is particularly high in the home setting and in semi-residential arrangements. These settings should be considered in interventions aiming to decrease the number of unwished care transitions and hospitalisations at the end of life.
Collapse
Affiliation(s)
- Rieke Schnakenberg
- Faculty of Medicine and Health Siences, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
| | - Alexander Maximilian Fassmer
- Faculty of Medicine and Health Siences, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Katharina Allers
- Faculty of Medicine and Health Siences, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Faculty of Medicine and Health Siences, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| |
Collapse
|
12
|
Quinn KL, Hsu AT, Meaney C, Qureshi D, Tanuseputro P, Seow H, Webber C, Fowler R, Downar J, Goldman R, Chan R, McGrail K, Isenberg SR. Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital. Palliat Med 2021; 35:1671-1681. [PMID: 33781119 PMCID: PMC8532234 DOI: 10.1177/02692163211002045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking. AIM The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use. SETTINGS AND PARTICIPANTS We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person's hospitalization in which they died. RESULTS Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use. CONCLUSIONS Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.
Collapse
Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,ICES, Toronto and Ottawa, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Amy T Hsu
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Christopher Meaney
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Danial Qureshi
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Colleen Webber
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Rob Fowler
- Tory Trauma Program, Sunnybrook Hospital, Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario
| | - James Downar
- Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Russell Goldman
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Temmy Latner Centre for Palliative Care and Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Raphael Chan
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, BC, Canada
| | - Sarina R Isenberg
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Ottawa, ON, Canada
| |
Collapse
|
13
|
Quinn KL, Stukel T, Huang A, Goldman R, Cram P, Detsky AS, Bell CM. Association Between Attending Physicians' Rates of Referral to Palliative Care and Location of Death in Hospitalized Adults With Serious Illness: A Population-based Cohort Study. Med Care 2021; 59:604-611. [PMID: 34100462 DOI: 10.1097/mlr.0000000000001524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients who receive palliative care are less likely to die in hospital. OBJECTIVE To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness. RESEARCH DESIGN Population-based decedent cohort study using linked health administrative data in Ontario, Canada. SUBJECTS A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016. EXPOSURE Physician annual rate of referral to palliative care (high, average, low). MEASURES Odds of death in hospital versus home, adjusted for patient characteristics. RESULTS There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)]. CONCLUSIONS AND RELEVANCE An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.
Collapse
Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
| | - Thérèse Stukel
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | | | - Russell Goldman
- Interdepartmental Division of Palliative Care, Sinai Health System
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
| | - Allan S Detsky
- Department of Medicine, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
| | - Chaim M Bell
- Department of Medicine, University of Toronto
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
| |
Collapse
|
14
|
Hanna N, Quach B, Scott M, Qureshi D, Tanuseputro P, Webber C. Operationalizing Burdensome Transitions Among Adults at the End of Life: A Scoping Review. J Pain Symptom Manage 2021; 61:1261-1277.e10. [PMID: 33096215 DOI: 10.1016/j.jpainsymman.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Care transitions at the end of life are associated with reduced quality of life and negative health outcomes, yet up to half of patients in developed countries experience a transition within the last month of life. A variety of these transitions have been described as "burdensome" in the literature; however, there is currently no consensus on the definition of a burdensome transition. OBJECTIVES The purpose of this review was to identify current definitions of "burdensome transitions" and develop a framework for classifying transitions as "burdensome" at the end of life. METHODS A search was conducted in databases including Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Controlled Register of Trials, CINAHL, and PsychINFO for articles published in English between January 1, 2000 and September 28, 2019. RESULTS A total of 37 articles met inclusion criteria for this scoping review. Definitions of burdensome transitions were characterized by the following features: transition setting trajectory, number of transitions, temporal relationship to end of life, or quality of transitions. CONCLUSION Definitions of burdensome transitions varied based on time before death, setting of cohorts, and study population. These definitions can be helpful in identifying and subsequently preventing unnecessary transitions at the end of life.
Collapse
Affiliation(s)
- Nardin Hanna
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada.
| | - Bradley Quach
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mary Scott
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danial Qureshi
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
15
|
Polypharmacy, inappropriate prescribing, and deprescribing in older people: through a sex and gender lens. LANCET HEALTHY LONGEVITY 2021; 2:e290-e300. [DOI: 10.1016/s2666-7568(21)00054-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 01/27/2023]
|
16
|
Applying the Knowledge-to-Action Framework to Engage Stakeholders and Solve Shared Challenges with Person-Centered Advance Care Planning in Long-Term Care Homes. Can J Aging 2021; 41:110-120. [PMID: 33583447 DOI: 10.1017/s0714980820000410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
As they near the end of life, long term care (LTC) residents often experience unmet needs and unnecessary hospital transfers, a reflection of suboptimal advance care planning (ACP). We applied the knowledge-to-action framework to identify shared barriers and solutions to ultimately improve the process of ACP and improve end-of-life care for LTC residents. We held a 1-day workshop for LTC residents, families, directors/administrators, ethicists, and clinicians from Manitoba, Alberta, and Ontario. The workshop aimed to identify: (1) shared understandings of ACP, (2) barriers to respecting resident wishes, and (3) solutions to better respect resident wishes. Plenary and group sessions were recorded and thematic analysis was performed. We identified four themes: (1) differing provincial frameworks, (2) shared challenges, (3) knowledge products, and 4) ongoing ACP. Theme 2 had four subthemes: (i) lacking clarity on substitute decision maker (SDM) identity, (ii) lacking clarity on the SDM role, (iii) failing to share sufficient information when residents formulate care wishes, and (iv) failing to communicate during a health crisis. These results have informed the development of a standardized ACP intervention currently being evaluated in a randomized trial in three Canadian provinces.
Collapse
|
17
|
Fairweather J, Cooper L, Sneddon J, Seaton RA. Antimicrobial use at the end of life: a scoping review. BMJ Support Palliat Care 2020:bmjspcare-2020-002558. [PMID: 33257407 DOI: 10.1136/bmjspcare-2020-002558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine antibiotic use in patients approaching end of life, in terms of frequency of prescription, aim of treatment, beneficial and adverse effects and contribution to the development of antimicrobial resistance. DESIGN Scoping review DATA SOURCES: An information scientist searched Ovid MEDLINE, Ovid EMBASE, The Cochrane library, PubMed Clinical Queries, NHS Evidence, Epistemonikos, SIGN, NICE, Google Scholar from inception to February 2019 for any study design including, but not limited to, randomised clinical trials, prospective interventional or observational studies, retrospective studies and qualitative studies. The search of Ovid MEDLINE was updated on the 10 June 2020. STUDY SELECTION Studies reporting antibiotic use in patients approaching end of life in any setting and clinicians' attitudes and behaviour in relation to antibiotic prescribing in this population DATA EXTRACTION: Two reviewers screened studies for eligibility; two reviewers extracted data from included studies. Data were analysed to describe antibiotic prescribing patterns across different patient populations, the benefits and adverse effects (for individual patients and wider society), the rationale for decision making and clinicians behaviours and attitudes to treatment with antibiotics in this patient group. RESULTS Eighty-eight studies were included. Definition of the end of life is highly variable as is use of antibiotics in patients approaching end of life. Prescribing decisions are influenced by patient age, primary diagnosis, care setting and therapy goals, although patients' preferences are not always documented or adhered to. Urinary and lower respiratory tract infections are the most commonly reported indications with outcomes in terms of symptom control and survival variably reported. Small numbers of studies reported on adverse events and antimicrobial resistance. Clinicians sometimes feel uncomfortable discussing antibiotic treatment at end of life and would benefit from guidelines to direct care. CONCLUSIONS Use of antibiotics in patients approaching the end of life is common although there is significant variation in practice. There are a myriad of intertwined biological, ethical, social, medicolegal and clinical issues associated with the topic.
Collapse
Affiliation(s)
| | - Lesley Cooper
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland Glasgow, Glasgow, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland Glasgow, Glasgow, UK
| | | |
Collapse
|
18
|
Factors Associated With Antimicrobial Use in Nursing Home Residents With Advanced Dementia. J Am Med Dir Assoc 2020; 22:178-181. [PMID: 32839124 DOI: 10.1016/j.jamda.2020.07.008] [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: 04/21/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Widespread antimicrobial misuse among nursing home (NH) residents with advanced dementia raises concerns regarding the emergence of multidrug-resistant organisms and avoidable treatment burden in this vulnerable population. The objective of this report was to identify facility and resident level characteristics associated with receipt of antimicrobials in this population. DESIGN Cross-sectional analysis of baseline data from the Trial to Reduce Antimicrobial use in Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD). SETTING AND PARTICIPANTS Twenty-eight Boston area NHs, 430 long stay NH residents with advanced dementia. MEASURES The outcome was the proportion of residents who received any antimicrobials during the 2 months prior to the start of TRAIN-AD determined by chart review. Multivariable logistic regression was used to identify resident and facility characteristics associated with this outcome. RESULTS A total of 13.7% of NH residents with advanced dementia received antimicrobials in the 2 months prior to the start of TRAIN-AD. Residents in facilities with the following characteristics were significantly more likely to receive antimicrobials: having a full time nurse practitioner/physician assistant on staff [adjusted odds ratio (aOR) 3.02; 95% confidence interval (CI), 1.54, 5.94], fewer existing infectious disease practices (eg, antimicrobial stewardship programs, established algorithms for infection management) (aOR, 2.35; 95% CI 1.14, 4.84), and having fewer residents with severely cognitively impaired residents (aOR 1.96; 95% CI 1.12, 3.40). No resident characteristics were independently associated with receipt of antimicrobials. CONCLUSIONS AND IMPLICATIONS Facility-level characteristics are associated with the receipt of antimicrobials among residents with advanced dementia. Implementation of more intense infectious disease practices and targeting the prescribing practices of nurse practitioners/physician assistants may be critical targets for interventions aimed at reducing antimicrobial use in this population.
Collapse
|
19
|
Quinn KL, Stukel T, Stall NM, Huang A, Isenberg S, Tanuseputro P, Goldman R, Cram P, Kavalieratos D, Detsky AS, Bell CM. Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study. BMJ 2020; 370:m2257. [PMID: 32631907 PMCID: PMC7336238 DOI: 10.1136/bmj.m2257] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level. DESIGN Population based matched cohort study. SETTING Ontario, Canada between 2010 and 2015. PARTICIPANTS 113 540 adults dying from cancer and non-cancer illness who were given newly initiated physician delivered palliative care in the last six months of life administered across all healthcare settings. Linked health administrative data were used to directly match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organise all healthcare services in Ontario), and a propensity score to receive palliative care that was derived by using age and sex. MAIN OUTCOME MEASURES Rates of emergency department visits, admissions to hospital, and admissions to the intensive care unit, and odds of death at home versus in hospital after first palliative care visit, adjusted for patient characteristics (such as age, sex, and comorbidities). RESULTS In patients dying from non-cancer illness related to chronic organ failure (such as heart failure, cirrhosis, and stroke), palliative care was associated with reduced rates of emergency department visits (crude rate 1.9 (standard deviation 6.2) v 2.9 (8.7) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.85 to 0.91), admissions to hospital (crude rate 6.1 (standard deviation 10.2) v 8.7 (12.6) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.86 to 0.91), and admissions to the intensive care unit (crude rate 1.4 (standard deviation 5.9) v 2.9 (8.7) per person year; adjusted rate ratio 0.59, 95% confidence interval 0.56 to 0.62) compared with those who did not receive palliative care. Additionally increased odds of dying at home or in a nursing home compared with dying in hospital were found in these patients (n=6936 (49.5%) v n=9526 (39.6%); adjusted odds ratio 1.67, 95% confidence interval 1.60 to 1.74). Overall, in patients dying from dementia, palliative care was associated with increased rates of emergency department visits (crude rate 1.2 (standard deviation 4.9) v 1.3 (5.5) per person year; adjusted rate ratio 1.06, 95% confidence interval 1.01 to 1.12) and admissions to hospital (crude rate 3.6 (standard deviation 8.2) v 2.8 (7.8) per person year; adjusted rate ratio 1.33, 95% confidence interval 1.27 to 1.39), and reduced odds of dying at home or in a nursing home (n=6667 (72.1%) v n=13 384 (83.5%); adjusted odds ratio 0.68, 95% confidence interval 0.64 to 0.73). However, these rates differed depending on whether patients dying with dementia lived in the community or in a nursing home. No association was found between healthcare use and palliative care for patients dying from dementia who lived in the community, and these patients had increased odds of dying at home. CONCLUSIONS These findings highlight the potential benefits of palliative care in some non-cancer illnesses. Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.
Collapse
Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Therese Stukel
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Nathan M Stall
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Anjie Huang
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
| | - Sarina Isenberg
- Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - Peter Tanuseputro
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Russell Goldman
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
- Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | | | - Allan S Detsky
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| |
Collapse
|
20
|
Sex-Specific Differences in Hospital Transfers of Nursing Home Residents: Results from the HOspitalizations and eMERgency Department Visits of Nursing Home Residents (HOMERN) Project. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17113915. [PMID: 32492840 PMCID: PMC7312075 DOI: 10.3390/ijerph17113915] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/25/2020] [Accepted: 05/29/2020] [Indexed: 01/04/2023]
Abstract
Nursing home (NH) residents are often transferred to hospital (emergency department (ED) visits or hospital admissions) and this occurs more frequently in males. However, respective reasons are rather unclear. We conducted a multicenter prospective study in 14 northwest German NHs with 802 residents in which NH staff recorded anonymized data between March 2018 and July 2019 for each hospital transfer. Measures were analyzed using descriptive statistics and compared between sexes via univariate logistic regression analyses using mixed models with random effects. Eighty-eight planned transfers (53.5% hospital admissions, 46.5% ED visits) occurred as well as 535 unplanned transfers (63.1% hospital admissions, 36.9% ED visits). The two most common causes for unplanned transfers were deteriorations of health status (35.1%) and falls/accidents/injuries (33.5%). Male transferred residents were younger, more often married; their advance directives were more commonly not considered correctly and the NH staff identified more males nearing the end of life than females (52.9% vs. 38.2%). Only 9.2% of transfers were rated avoidable. For advance directive availability and NH staff’s perceptions on transfer conditions, we found marked inter-facility differences. There might be sociocultural factors influencing hospital transfer decisions of male and female nursing home residents and facility characteristics that may affect transfer policy.
Collapse
|
21
|
Rausch C, Hoffmann F. Prescribing medications of questionable benefit prior to death: a retrospective study on older nursing home residents with and without dementia in Germany. Eur J Clin Pharmacol 2020; 76:877-885. [PMID: 32219538 PMCID: PMC7239800 DOI: 10.1007/s00228-020-02859-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/11/2020] [Indexed: 12/04/2022]
Abstract
Purpose We studied the prevalence of medications of questionable benefit in the last 6 months of life among older nursing home residents with and without dementia in Germany. Methods A retrospective cohort study was conducted on claims data from 67,328 deceased nursing home residents aged 65+ years who were admitted between 2010 and 2014. We analyzed prescription regimens of medications of questionable benefit in the 180–91-day period and the 90-day period prior to death for residents with dementia (n = 29,052) and without dementia (n = 38,276). Factors associated with new prescriptions of medications of questionable benefit prior to death were analyzed using logistic regression models among all nursing home residents and stratified by dementia. Results A higher proportion of nursing home residents with dementia were prescribed at least one medication of questionable benefit in the 180–91-day (29.6%) and 90-day (26.8%) periods prior to death, compared with residents without dementia (180–91 days, 22.8%; 90 days, 20.1%). Lipid-lowering agents were the most commonly prescribed medications. New prescriptions of medications of questionable benefit were more common among residents with dementia (9.8% vs. 8.7%). When excluding anti-dementia medication, new prescriptions of these medications were more common among residents without dementia (6.4% vs. 8.0%). The presence of dementia (odds ratio [OR] 1.40, 95% confidence interval [95%CI] 1.32–1.48) and excessive polypharmacy were associated with new prescriptions of medications of questionable benefit prior to death (OR 4.74, 95%CI 4.15–5.42). Conclusion Even when accounting for anti-dementia prescriptions, the prevalence of nursing home residents with dementia receiving medications of questionable benefit is considerable and may require further attention. Electronic supplementary material The online version of this article (10.1007/s00228-020-02859-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Christian Rausch
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany.
- Department of Health Sciences, Community and Occupational Medicine, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, FA10, 9713 AV, Groningen, The Netherlands.
- Department of Global Public Health, Karolinska Institutet, Widerströmska huset, Tomtebodavägen 18A, SE, 17177, Stockholm, Sweden.
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany
| |
Collapse
|
22
|
Hoffmann F, Allers K. Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015. Maturitas 2020; 134:47-53. [PMID: 32143776 DOI: 10.1016/j.maturitas.2020.02.006] [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: 09/21/2019] [Revised: 02/03/2020] [Accepted: 02/18/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES We investigated trends in end-of-life hospitalizations among nursing home residents (NHR) over 10 years and looked at differences between age groups and sexes as well as the length of terminal hospital stays. STUDY DESIGN Retrospective cohort study based on health insurance claims data of the AOK Bremen/Bremerhaven. All NHR aged 65 years or more who died between 2006 and 2015 were included. MAIN OUTCOME MEASURES We assessed the proportions of decedents who were in hospital on the day of death and during the last 3, 7, 14 and 30 days of life, stratified by two-year periods. Multiple logistic regressions were conducted to study changes over time, adjusting for covariates. RESULTS A total of 10,781 decedents were included (mean age 86.1 years, 72.1 % females). Overall, 29.2 % died in hospital, with a slight decrease from 30.3 % in 2006-2007 to 28.3 % in 2014-2015 (OR 0.86; 95 % CI 0.75-0.98). Of the 3150 terminal hospitalizations, 35.5 % lasted up to 3 days and the mean length of stay decreased from 9.0 (2006-2007) to 7.5 days (2014-2015). When looking at the last 7, 14 and 30 days of life, no changes over time were found. Male sex and younger age were associated with a higher chance of end-of-life hospitalization in almost all analyses. CONCLUSIONS End-of-life hospitalizations of NHR are common in Germany. There has been a small decrease during recent years in the proportion of in-hospital deaths, but not of hospitalizations during the last 7, 14 and 30 days of life. This might be explained by shorter durations of hospital stays.
Collapse
Affiliation(s)
- Falk Hoffmann
- Carl von Ossietzky University Oldenburg, Department of Health Services Research, Oldenburg, Germany.
| | - Katharina Allers
- Carl von Ossietzky University Oldenburg, Department of Health Services Research, Oldenburg, Germany
| |
Collapse
|
23
|
Sun Y, Guo Y, Feng X, Jia M, Ai N, Dong Y, Zheng Y, Fu L, Yu B, Zhang H, Wu J, Yu X, Wu H, Kong W. The behavioural and neuropathologic sexual dimorphism and absence of MIP-3α in tau P301S mouse model of Alzheimer's disease. J Neuroinflammation 2020; 17:72. [PMID: 32093751 PMCID: PMC7041244 DOI: 10.1186/s12974-020-01749-w] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/17/2020] [Indexed: 12/27/2022] Open
Abstract
Background Tau hyper-phosphorylation has been considered a major contributor to neurodegeneration in Alzheimer’s disease (AD) and related tauopathies, and has gained prominence in therapeutic development for AD. To elucidate the pathogenic mechanisms underlying AD and evaluate therapeutic approaches targeting tau, numerous transgenic mouse models that recapitulate critical AD-like pathology have been developed. Tau P301S transgenic mice is one of the most widely used mouse models in AD research. Extensive studies have demonstrated that sex significantly influences AD pathology, behavioral status, and therapeutic outcomes, suggesting that studies using mouse models of AD must consider sex- and age-related differences in neuropathology, behavior, and plasma content. Method We systematically investigated differences in tau P301S transgenic mice (PS19 line) and wildtype littermates of different sex behavioral performance, tau neuropathology, and biomarkers in plasma and brain. Results Male P301S transgenic mice exhibited significant changes in weight loss, survival rate, clasping, kyphosis, composite phenotype assessment, nest building performance, tau phosphorylation at Ser202/Thr205, and astrocyte activation compared to that of wild-type littermates. In contrast, female P301S transgenic mice were only sensitive in the Morris water maze and open field test. In addition, we characterized the absence of macrophage-inflammatory protein (MIP-3α) and the upregulation of interferon (IFN)-γ, interleukin (IL)-5, and IL-6 in the plasma of P301S transgenic mice, which can be served as potential plasma biomarkers in P301S Tg mice. Male P301S transgenic mice expressed more monokine induced by IFN-γ (MIG), tumor necrosis factor-α (TNF-α), IL-10, and IL-13 than those of female P301S mice. Conclusion Our findings highlight sexual dimorphism in the behavior, neuropathology, and plasma proteins in tau P301S transgenic AD mice, indicating that the use of male P301S transgenic mice may be more suitable for assessing anti-phosphorylated tau therapeutic strategies for AD and related tauopathies, and the MIP-3α may be a new potential plasma biomarker.
Collapse
Affiliation(s)
- Yao Sun
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China
| | - Yongqing Guo
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China.,State Key Laboratory of Molecular Developmental Biology, Institute of Genetics and Developmental Biology, Chinese Academy of Sciences, Beijing, 100101, China
| | - Xuejian Feng
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China
| | - Meng Jia
- Department of Pathology, The Second Hospital of Jilin University, Changchun, 130041, Jilin, China
| | - Ning Ai
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China
| | - Yue Dong
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China
| | - Yayuan Zheng
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China
| | - Lu Fu
- Laboratory of Pathogenic Microbiology and Immunology, College of life science, Jilin Agricultural University, Changchun, 130012, China
| | - Bin Yu
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China.,Key Laboratory for Molecular Enzymology and Engineering, the Ministry of Education, School of Life Sciences, Jilin University, Changchun, 130012, China
| | - Haihong Zhang
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China.,Key Laboratory for Molecular Enzymology and Engineering, the Ministry of Education, School of Life Sciences, Jilin University, Changchun, 130012, China
| | - Jiaxin Wu
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China.,Key Laboratory for Molecular Enzymology and Engineering, the Ministry of Education, School of Life Sciences, Jilin University, Changchun, 130012, China
| | - Xianghui Yu
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China.,Key Laboratory for Molecular Enzymology and Engineering, the Ministry of Education, School of Life Sciences, Jilin University, Changchun, 130012, China
| | - Hui Wu
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China. .,Key Laboratory for Molecular Enzymology and Engineering, the Ministry of Education, School of Life Sciences, Jilin University, Changchun, 130012, China.
| | - Wei Kong
- National Engineering Laboratory for AIDS Vaccine, School of Life Sciences, Jilin University, Changchun, 130012, China. .,Key Laboratory for Molecular Enzymology and Engineering, the Ministry of Education, School of Life Sciences, Jilin University, Changchun, 130012, China.
| |
Collapse
|