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Kosar CM, Thapa BB, Muench U, Santostefano C, Gadbois EA, Oh H, Gozalo PL, Rahman M, White EM. Nurse Practitioner Care, Scope of Practice, and End-of-Life Outcomes for Nursing Home Residents With Dementia. JAMA HEALTH FORUM 2024; 5:e240825. [PMID: 38728021 PMCID: PMC11087831 DOI: 10.1001/jamahealthforum.2024.0825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/07/2024] [Indexed: 05/13/2024] Open
Abstract
Importance Nursing home residents with Alzheimer disease and related dementias (ADRD) often receive burdensome care at the end of life. Nurse practitioners (NPs) provide an increasing share of primary care in nursing homes, but how NP care is associated with end-of-life outcomes for this population is unknown. Objectives To examine the association of NP care with end-of-life outcomes for nursing home residents with ADRD and assess whether these associations differ according to state-level NP scope of practice regulations. Design, Setting, and Participants This cohort study using fee-for-service Medicare claims included 334 618 US nursing home residents with ADRD who died between January 1, 2016, and December 31, 2018. Data were analyzed from April 6, 2015, to December 31, 2018. Exposures Share of nursing home primary care visits by NPs, classified as minimal (<10% of visits), moderate (10%-50% of visits), and extensive (>50% of visits). State NP scope of practice regulations were classified as full vs restrictive in 2 domains: practice authority (authorization to practice and prescribe independently) and do-not-resuscitate (DNR) authority (authorization to sign DNR orders). Main Outcomes and Measures Hospitalization within the last 30 days of life and death with hospice. Linear probability models with hospital referral region fixed effects controlling for resident characteristics, visit volume, and geographic factors were used to estimate whether the associations between NP care and outcomes varied across states with different scope of practice regulations. Results Among 334 618 nursing home decedents (mean [SD] age at death, 86.6 [8.2] years; 69.3% female), 40.5% received minimal NP care, 21.4% received moderate NP care, and 38.0% received extensive NP care. Adjusted hospitalization rates were lower for residents with extensive NP care (31.6% [95% CI, 31.4%-31.9%]) vs minimal NP care (32.3% [95% CI, 32.1%-32.6%]), whereas adjusted hospice rates were higher for residents with extensive (55.6% [95% CI, 55.3%-55.9%]) vs minimal (53.6% [95% CI, 53.3%-53.8%]) NP care. However, there was significant variation by state scope of practice. For example, in full practice authority states, adjusted hospice rates were 2.88 percentage points higher (95% CI, 1.99-3.77; P < .001) for residents with extensive vs minimal NP care, but the difference between these same groups was 1.77 percentage points (95% CI, 1.32-2.23; P < .001) in restricted practice states. Hospitalization rates were 1.76 percentage points lower (95% CI, -2.52 to -1.00; P < .001) for decedents with extensive vs minimal NP care in full practice authority states, but the difference between these same groups in restricted practice states was only 0.43 percentage points (95% CI, -0.84 to -0.01; P < .04). Similar patterns were observed in analyses focused on DNR authority. Conclusions and Relevance The findings of this cohort study suggest that NPs appear to be important care providers during the end-of-life period for many nursing home residents with ADRD and that regulations governing NP scope of practice may have implications for end-of-life hospitalizations and hospice use in this population.
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Affiliation(s)
- Cyrus M. Kosar
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Bishnu B. Thapa
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ulrike Muench
- Department of Social Behavioral Sciences, University of California at San Francisco School of Nursing, San Francisco
| | - Christopher Santostefano
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Emily A. Gadbois
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Hyesung Oh
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L. Gozalo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Elizabeth M. White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
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Dash D, Moser A, Feldman S, Saliba D, Bakaev I, Smalbrugge M, Robert B, Karuza J, Heckman G, Katz PR, Costa AP. Focusing on Provider Quality Measurement: Continued Consensus and Feasibility Testing of Practice-Based Quality Measures for Primary Care Providers in Long-Term Care. J Am Med Dir Assoc 2024; 25:189-194. [PMID: 38101456 DOI: 10.1016/j.jamda.2023.10.024] [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: 08/17/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 12/17/2023]
Abstract
Medical providers in long-term care (LTC) use a unique skillset in delivering comprehensive resident care. Publicly reported quality measures (QMs) do not directly emphasize medical provider competency and their role in care. The impact of providers is understudied and to a large extent, unknown. Our objective was to define, test, and validate QMs to pragmatically measure the practice-based quality of medical providers in a pilot study. We included 7 North American LTC homes with data from practicing medical providers for LTC residents. We engaged in a 4-phased approach. In phase 1, experts rated 95 candidate QMs using 5 pragmatic-focused criteria in a RAND-modified Delphi process. Phase 2 involved specifying 37 QMs for collection (4 QMs were dropped during pilot testing). We created an abstraction manual and data collection tool for all QMs. Phase 3 involved a retrospective chart review in 7 LTC homes on 33 QMs with trained data abstractors. Data were sufficient to analyze performance for 26 QMs. Lastly, in phase 4 results and psychometric properties were reviewed with an expert panel. They ranked the tested measures for validity and feasibility for use by a nonphysician auditor to evaluate medical provider performance based on medical record review. In total, we examined data from 343 resident charts from 7 LTC homes and 49 providers. Our process yielded 10 QMs as being specified for measurement, feasible to collect, and had good test performance. This is the only study to systematically identify a subset of QMs for feasible collection from the medical record by various data collectors. This pragmatic approach to measuring practice-based quality and quantifying select medical provider competencies allows for the evaluation of individual and facility-level performance and facilitates quality improvement initiatives. Future work should perform broader testing and validate and refine operationalized QMs.
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Affiliation(s)
- Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrea Moser
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Senior Services and Long-Term Care Division, City of Toronto, Toronto, ON, Canada
| | - Sid Feldman
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Baycrest Health Sciences, Toronto, ON, Canada
| | - Debra Saliba
- University of California Los Angeles, Borun Center at David Geffen School of Medicine, Los Angeles, CA, USA; Geriatric Research, Education, and Clinical Centers, Veterans Administration, Los Angeles, CA, USA; RAND Corporation, Santa Monica, CA, USA
| | - Innokentiy Bakaev
- Department of Medicine, Hebrew SeniorLife, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Benoît Robert
- Perley Health, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, ON, Canada
| | - Jurgis Karuza
- Division of Geriatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - George Heckman
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Waterloo, ON, Canada
| | - Paul R Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
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Riester MR, Douglas CM, Silva JB, Datta R, Zullo AR. Clinicians who primarily practice in nursing homes and outcomes among residents with urinary tract infection or pneumonia. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e253. [PMID: 38178878 PMCID: PMC10762639 DOI: 10.1017/ash.2023.527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024]
Abstract
Objective Assess the association between clinicians who primarily practice in nursing homes (NHs) and 14-day resident outcomes following initial antibiotic dispensing for pneumonia or urinary tract infection (UTI). Design Retrospective cohort. Setting U.S. NHs. Participants NH residents aged ≥65 years who were prescribed antibiotics for pneumonia or UTI between 1 January 2016 and 30 November 2018. Methods Medicare fee-for-service claims were linked to Minimum Data Set data. Clinicians who primarily practiced in NHs prescribed ≥90% of Part D dispensings to NH residents. Outcomes included death, all-cause and infection-specific hospitalization, and subsequent antibiotic dispensing. Adjusted risk ratios were estimated using inverse-probability-of-treatment-weighted (IPTW) modified Poisson regression models adjusting for 53 covariates. Results The study population included 28,826 resident-years who were prescribed antibiotics for pneumonia and 106,354 resident-years who were prescribed antibiotics for UTI. Among the pneumonia group, clinicians who primarily practiced in NHs were associated with a greater risk of death (RR 1.3; 95%CLs 1.0, 1.6), lower risks of all-cause (RR 0.9; 95%CLs 0.8, 0.9) and infection-specific hospitalization (RR 0.8; 95%CLs 0.7, 0.9), and similar risk of subsequent antibiotic dispensing (RR 1.0; 95%CLs 1.0, 1.1) after IPTW. No meaningful associations were observed between clinicians who primarily practiced in NHs and outcomes among the UTI group. Conclusions Clinicians who primarily practiced in NHs were associated with a lower risk of hospitalization but greater risk of mortality for NH residents with pneumonia. Further examination is needed to better understand drivers of differences in infection-related outcomes based on clinicians' training and primary practice setting.
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Affiliation(s)
- Melissa R. Riester
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Cody M. Douglas
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Joe B.B. Silva
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Rupak Datta
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrew R. Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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McGarry BE, Sommers BD, Barnett ML. Treatment of SARS-CoV-2 Infection in US Nursing Homes-Reply. JAMA 2023; 330:2022. [PMID: 38015222 DOI: 10.1001/jama.2023.20018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Brian E McGarry
- Department of Medicine, University of Rochester, Rochester, New York
| | - Benjamin D Sommers
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Katz PR, Resnick B. The Sky Is Falling Revisited. J Am Med Dir Assoc 2023; 24:1615-1618. [PMID: 37898536 DOI: 10.1016/j.jamda.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 09/21/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Paul R Katz
- Department of Geriatrics, Florida State University College of Medicine, Tallahassee, FL, USA.
| | - Barbara Resnick
- University of Maryland School of Nursing, College Park, MD, USA
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Dash D, Siu H, Kirkwood D, Correia RH, Katz P, Moser A, von Schlegell A, Collins R, Costa AP. Did the Long-Term Care Physician Workforce Change During the Pandemic? Describing MRP Trends in Ontario, Canada. J Am Med Dir Assoc 2023; 24:1042-1047.e1. [PMID: 37160254 DOI: 10.1016/j.jamda.2023.03.036] [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: 02/10/2023] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVES To examine the practice patterns and trends of long-term care (LTC) physicians between 2019 and 2021 in Ontario, Canada. DESIGN Population-level descriptive time trend study. SETTING AND PARTICIPANTS Most responsible physicians (MRPs) of LTC residents of publicly funded LTC homes in Ontario, Canada, from September 2019 to December 2021. METHODS We examined the number of MRPs in publicly regulated Ontario LTC homes before and during the COVID-19 pandemic using population-level administrative databases. Characteristics of MRPs and practice patterns were generated at baseline and across distinct time periods of the pandemic in descriptive tables. We created a Sankey diagram to visualize MRP practice changes over time. RESULTS More than one-quarter of pre-pandemic MRPs were no longer MRPs by the end of 2021, although most continued to practice in non-LTC settings. There was a decrease from 1444 to 1266 MRPs over time. Other characteristics of MRPs remained stable over the pandemic time periods. At baseline, LTC physicians were MRP for an average of 57.3 residents. By the end of 2021, this caseload decreased to 53.3 residents per MRP. MRPs increasingly billed monthly management compensation fees over the fee-for-service model across the pandemic time periods. The number of MRPs working in an LTC home shifted to fewer MRPs per home. CONCLUSIONS AND IMPLICATIONS MRP demographic characteristics did not change over the course of the pandemic. The observed shifts in practice patterns showed a reduction in the overall LTC MRP workforce, who delivered care to fewer residents on average in LTC homes with fewer colleagues to rely on. Future work can study how changes to LTC MRPs' practice patterns impact physician coverage, access and continuity of care, and health services and quality outcomes among residents.
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Affiliation(s)
- Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Henry Siu
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Rebecca H Correia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paul Katz
- Department of Geriatrics, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Andrea Moser
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; City of Toronto Senior Services and Long-Term Care Division, Toronto, Ontario, Canada
| | - Ahmed von Schlegell
- Trillium Health Partners, Mississauga, Ontario, Canada; Schlegel Villages, Kitchener, Ontario, Canada; DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada
| | - Rhonda Collins
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada.
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Cook KL, Mayahara M, Tivis L. Evaluation of the Nurse Practitioner Offsite Model. J Gerontol Nurs 2023; 49:25-30. [PMID: 37379050 DOI: 10.3928/00989134-20230615-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Rural older adults residing in assisted living (AL) (herein referred to as residents) have limited access to health care for urgent and chronic management of diseases. The current project aimed to assess rural residents, families, and staff satisfaction with the Nurse Practitioner (NP) Offsite Visit Program. Residents and their families were asked to complete the NP Satisfaction Survey. The survey comprised three subscales (satisfaction, communication, and accessibility) and measured residents' and families' satisfaction. AL staff attended a 1-hour focus interview. Mean survey scores were 81.5 for satisfaction, 26.4 for communication, and 16.9 for accessibility subscales. Focus interview themes included Care Coordination, Prevention of Acute Care Utilization, and Access to Care. Findings suggest that residents, families, and site staff believe the NP Offsite Visit Program was beneficial and improved care coordination between residents and the provider team. The next step is to evaluate the program's impact on residents' health outcomes and further evaluate the Offsite team membership. [Journal of Gerontological Nursing, 49(7), 25-30.].
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Katz PR, Smith BJ, Gilberstadt NJ, Rust C, Rosasco R. Physician Practice Characteristics Influencing Nurse Practitioner and Physician Assistant Care in Nursing Homes: A Scoping Review. J Am Med Dir Assoc 2023; 24:599-608. [PMID: 36958373 DOI: 10.1016/j.jamda.2023.02.013] [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: 10/26/2022] [Revised: 01/26/2023] [Accepted: 02/11/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVES Physicians, nurse practitioners (NPs), and physician assistants (PAs) are key to the effective delivery of medical care in nursing homes (NHs). Although several studies have reported on the relationship between the care delivered by a given discipline and specific clinical outcomes, the mediating effect of physician practice characteristics is unknown. A scoping review was conducted to determine whether studies examining the impact of NP and PA care in NHs have accounted for both the collaborative relationship between themselves and physicians as well as physician practice size and type. DESIGN Scoping review. SETTINGS AND PARTICIPANTS NH and NH residents. METHODS Papers eligible for review included peer-reviewed studies written in English and that were quantitative in nature. Inclusion criteria required that more than 1 NH and more than a single NP or PA be included for the analysis. Further, the size of the NH studied must have equaled or exceeded 100 residents and more than 1 clinical outcome reported. Databases searched included Ovid MEDLINE, Cochrane Library, Web of Science; CINAHL, and AgeLine. RESULTS A total of 1878 studies underwent abstract review of which 1719 were excluded. A full-text review of the remaining articles was completed (n = 157, as 2 articles could not be retrieved), of which 16 met eligibility criteria. The study designs were generally retrospective and quasi-experimental in nature. No randomized controlled studies were identified. Physician practice variables such as number of physicians, total practice case load, case mix, and the nature of the collaborative practice between NP/PA and MD were infrequently specified. In no reports was the type of physician practice characterized and no physician practice variables were adjusted for with regard to outcomes. CONCLUSIONS None of the studies included in the review were found to have incorporated any physician variables into their outcome analyses. Before purporting equivalency between medical provider disciplines in NHs, future studies must, at the very least, consider the mediating effect of physician practice characteristics.
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Affiliation(s)
- Paul R Katz
- Florida State University, Tallahassee, FL, USA.
| | | | | | - Casey Rust
- Florida State University, Tallahassee, FL, USA
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Katz PR, Smalbrugge M, Karuza J, Costa A, Nazir A, Wasserman MR, Nelson D, Levenson SA, Resnick B. Raising the Bar for Physicians Practicing in Nursing Homes: The Path to Sustainable Improvement. J Am Med Dir Assoc 2023; 24:131-133. [PMID: 36725202 DOI: 10.1016/j.jamda.2022.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Paul R Katz
- Department of Geriatrics, FSU College of Medicine, Tallahassee, FL, USA.
| | - Martin Smalbrugge
- Department of Medicine for Older People Vrije University and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Jurgis Karuza
- Division of Geriatrics, University of Rochester, Rochester, NY, USA
| | - Andrew Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Arif Nazir
- Chief Medical Officer, Primary Care at BrightSpring Health Services, Louisville, KY, USA
| | | | - Dallas Nelson
- Division of Geriatrics, University of Rochester, Rochester, NY, USA
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Correia RH, Dash D, Poss JW, Moser A, Katz PR, Costa AP. Physician Practice in Ontario Nursing Homes: Defining Physician Commitment. J Am Med Dir Assoc 2022; 23:1942-1947.e2. [PMID: 35609638 DOI: 10.1016/j.jamda.2022.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/31/2022] [Accepted: 04/17/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To characterize the practice profile of nursing home (NH) physicians in Ontario, Canada. DESIGN Population-based cross-sectional study. SETTING AND PARTICIPANTS A total of 1527 most responsible physicians (MRPs) across 626 NHs in Ontario, Canada, for the calendar year, 2017. METHODS We examined physician services within all publicly regulated and funded NH facilities. Descriptive summaries were generated to characterize MRPs and their practice patterns by the physician's primary practice location, the NH facility size, and the proportion of physician billings that occurred within NHs. Community sizes were classified into quintiles based on population size and assigned as urban or rural. The number of ministry-designated NH beds were assessed by quintiles to examine physician services by facility size. We also assessed the proportion of physician billings within NHs by quintiles. RESULTS MRPs tended to be older, male, and practice family medicine. The majority of MRPs practiced in communities with populations exceeding 100,000 residents, although physicians with greater NH billings tended to practice in rural locations. The mean number of NH residents that a physician was MRP for was positively associated with the community size. Physicians provided care for more NH residents than they were assigned most responsible. Fifty-one percent of physicians were MRP for 90% of all NH residents. CONCLUSIONS AND IMPLICATIONS Our work provides an exemplar for characterizing physician commitment in NHs, using 2 approaches, according to the NH specialist model. We demonstrated the medical practice characteristics, locations, and billing patterns of physicians within Ontario NHs. Future work can investigate the association between physician commitment and the quality of care provided to NH residents. A greater understanding of physician commitment may lead to the development of quality metrics based on physician practice patterns.
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Affiliation(s)
- Rebecca H Correia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey W Poss
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Andrea Moser
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Paul R Katz
- Department of Geriatrics, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
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Collins RL, Williams EM, Moser AL, Varughese JM, Robert B. The Role of the Medical Director in Ontario Long-Term Care Homes: Impact of COVID-19. J Am Med Dir Assoc 2022; 23:1603-1607. [PMID: 35944589 PMCID: PMC9289006 DOI: 10.1016/j.jamda.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 11/20/2022]
Abstract
Objectives The pandemic has uncovered a broad lack of understanding of the role of the Medical Director in Canadian Long-Term Care (LTC) Homes. Our objectives were to identify the current demographics and practices of LTC Medical Directors, discover how the pandemic affected their practice habits, and inform the content of the Ontario Long-Term Care Clinicians Medical Director Course, to ensure that Medical Directors have the requisite knowledge of the responsibilities of their role. Design Email survey. Setting and Participants Medical directors in Ontario long-term care homes. Methods Responses to open-ended, close-ended, multiple-choice, and free-text questions. Results A total of 156 medical directors (approximately 24%) completed the survey. Ninety-four percent were family physicians. Approximately 40% of participants had been a medical director for fewer than 5 years, whereas more than 11% have been in the role for greater than 30 years. More than 60% spend fewer than 2 hours per week in their administrative role, with fewer than 23% completing formal evaluations of the attending clinicians. Greater than 75% are either satisfied or extremely satisfied in their medical director role, citing excellent engagement and collaboration with team members. Feelings of dissatisfaction were associated with pandemic stress, increased hours and responsibility, inadequate remuneration, lack of ability to make decisions and lack of acknowledgement that physicians add value to the interdisciplinary team. Conclusion and Implications It is clear that medical directors are in a unique position to impact the care of residents within LTC. It is imperative to engage medical directors as integral members of the LTC health care team. This can be achieved by acknowledging their medical expertise for improving outcomes, providing them with the authority for decision making, compensating them appropriately, and clearly defining the role. By making these changes, we can ensure that there is a higher likelihood to sustain effective medical leadership in LTC.
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Correia RH, Mowbray FI, Dash D, Katz PR, Moser A, Strum RP, Jones A, von Schlegell A, Costa AP. Clinical factors associated with recent medical care visits in nursing homes: a multi-site cross-sectional study. BMC Geriatr 2022; 22:320. [PMID: 35413884 PMCID: PMC9003172 DOI: 10.1186/s12877-022-03011-9] [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: 10/01/2021] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Abstract
Objectives We examined which resident-level clinical factors influence the provision of a recent medical care visit in nursing homes (NHs). Design Multi-site cross-sectional. Setting and participants We extracted data on 3,556 NH residents from 18 NH facilities in Ontario, Canada, who received at minimum, an admission and first-quarterly assessment with the Resident Assessment Instrument Minimum Data Set (MDS) 2.0 between November 1, 2009, and October 31, 2017. Methods We conducted a secondary analysis of routinely collected MDS 2.0 data. The provision of a recent medical care visit by a physician (or authorized clinician) was assessed in the 14-day period preceding a resident’s first-quarterly MDS 2.0 assessment. We utilized best-subset multivariable logistic regression to model the adjusted associations between resident-level clinical factors and a recent medical care visit. Results Two thousand eight hundred fifty nine (80.4%) NH residents had one or more medical care visits prior to their first-quarterly MDS 2.0 assessment. Six clinically relevant factors were identified to be associated with recent medical care visits in the final model: exhibiting wandering behaviours (OR = 1.34, 95% CI 1.09 – 1.63), presence of a pressure ulcer (OR = 1.37, 95% CI 1.05 – 1.78), a urinary tract infection (UTI) (OR = 1.52, 95% CI 1.06 – 2.18), end-stage disease (OR = 9.70, 95% CI 1.32 – 71.02), new medication use (OR = 1.31, 95% CI 1.09 – 1.57), and analgesic use (OR = 1.24, 95% CI 1.03 – 1.49). Conclusions and implications Our findings suggest that resident-level clinical factors drive the provision of medical care visits following NH admission. Clinical factors associated with medical care visits align with the minimum competencies expected of physicians in NH practice, including managing safety risks, infections, medications, and death. Ensuring that NH physicians have opportunities to acquire and strengthen these competencies may be transformative to meet the ongoing needs of NH residents. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03011-9.
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Affiliation(s)
- Rebecca H Correia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Paul R Katz
- Department of Geriatrics, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Andrea Moser
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Ryan P Strum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ahmad von Schlegell
- Trillium Health Partners, Mississauga, ON, Canada.,Schlegel Villages, Kitchener, ON, Canada.,DeGroote School of Business, McMaster University, Hamilton, ON, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Correia RH, Jabbar A, Siu HYH, Hogeveen S, Dash D, Mowbray FI, Costa AP, Vanstone M. Comparing the scopes of practice of geriatric-focused physicians in Canada: a qualitative study of core competencies. CMAJ Open 2022; 10:E563-E569. [PMID: 35728839 PMCID: PMC9343128 DOI: 10.9778/cmajo.20210193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Given long-standing deficits of medical expertise to care for a growing population of older adults, it is important to understand the geriatric medical workforce. We aimed to describe and compare the scopes of practice of the 3 geriatric-focused physician providers in Canada (i.e., family physicians with certification in Care of the Elderly [FM-COE], geriatricians and geriatric psychiatrists). METHODS We conducted a qualitative study to compare competencies across geriatric-focused physician provider types in Canada, using a directed content analysis approach. We identified and obtained relevant publicly available documents that described the competencies required for certification by searching the websites of The College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada between June 2 and July 31, 2020. An inductive content analysis was used to compare content within each CanMEDS Role according to the CanMEDS Framework. RESULTS We identified and obtained 4 relevant publicly available documents describing the competencies required for geriatric-focused certification for the 3 geriatric-focused physician provider types. We found substantial overlaps in the expected medical expertise of FM-COE and geriatricians. The few substantive differences across providers may result from different priorities about which competencies were made explicit for providers. The focused nature of mental health care is apparent in several competencies unique to geriatric psychiatry. INTERPRETATION This work highlights substantial overlaps in the scopes of practice for FM-COE and geriatricians. Our findings may encourage efforts to develop more robust delineations between the scopes of practice of these related professionals to facilitate inter-specialty collaboration to lead to more equitable and accessible medical care for older adults.
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Affiliation(s)
- Rebecca H Correia
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont.
| | - Amina Jabbar
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Henry Yu-Hin Siu
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Sophie Hogeveen
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Darly Dash
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Andrew P Costa
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Meredith Vanstone
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
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Jung HY, Yun H, O'Donnell E, Casalino LP, Unruh MA, Katz PR. Defining the Role and Value of Physicians Who Primarily Practice in Nursing Homes: Perspectives of Nursing Home Physicians. J Am Med Dir Assoc 2022; 23:962-967.e2. [DOI: 10.1016/j.jamda.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/22/2022] [Accepted: 03/12/2022] [Indexed: 12/01/2022]
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15
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Garland A, Keller H, Quail P, Boscart V, Heyer M, Ramsey C, Vucea V, Choi N, Bains I, King S, Oshchepkova T, Kalashnikova T, Kroetsch B, Steer J, Heckman G. BABEL (Better tArgeting, Better outcomes for frail ELderly patients) advance care planning: a comprehensive approach to advance care planning in nursing homes: a cluster randomised trial. Age Ageing 2022; 51:6552807. [PMID: 35325020 PMCID: PMC8946666 DOI: 10.1093/ageing/afac049] [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: 09/24/2021] [Revised: 12/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background Nursing home (NH) residents should have the opportunity to consider, discuss and document their healthcare wishes. However, such advance care planning (ACP) is frequently suboptimal. Objective Assess a comprehensive, person-centred ACP approach. Design Unblinded, cluster randomised trial. Setting Fourteen control and 15 intervention NHs in three Canadian provinces, 2018–2020. Subjects 713 residents (442 control, 271 intervention) aged ≥65 years, with elevated mortality risk. Methods The intervention was a structured, \documentclass[12pt]{minimal}
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}{}$\sim$\end{document}60-min discussion between a resident, substitute decision-maker (SDM) and nursing home staff to: (i) confirm SDMs’ identities and role; (ii) prepare SDMs for medical emergencies; (iii) explain residents’ clinical condition and prognosis; (iv) ascertain residents’ preferred philosophy to guide decision-making and (v) identify residents’ preferred options for specific medical emergencies. Control NHs continued their usual ACP processes. Co-primary outcomes were: (a) comprehensiveness of advance care planning, assessed using the Audit of Advance Care Planning, and (b) Comfort Assessment in Dying. Ten secondary outcomes were assessed. P-values were adjusted for all 12 outcomes using the false discovery rate method. Results The intervention resulted in 5.21-fold higher odds of respondents rating ACP comprehensiveness as being better (95% confidence interval [CI] 3.53, 7.61). Comfort in dying did not differ (difference = −0.61; 95% CI −2.2, 1.0). Among the secondary outcomes, antimicrobial use was significantly lower in intervention homes (rate ratio = 0.79, 95% CI 0.66, 0.94). Conclusions Superior comprehensiveness of the BABEL approach to ACP underscores the importance of allowing adequate time to address all important aspects of ACP and may reduce unwanted interventions towards the end of life.
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Affiliation(s)
- Allan Garland
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Heather Keller
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Patrick Quail
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Veronique Boscart
- School of Health and Life Sciences, Conestoga College, Kitchener, Ontario, Canada
| | - Michelle Heyer
- School of Health and Life Sciences, Conestoga College, Kitchener, Ontario, Canada
| | - Clare Ramsey
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Vanessa Vucea
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Nora Choi
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ikdip Bains
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Seema King
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tatiana Oshchepkova
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Brittany Kroetsch
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Jessica Steer
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - George Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
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Katz PR, Howd S, Rust C. Reimagining Medical Care in Assisted Living. J Am Med Dir Assoc 2022; 23:201-203. [PMID: 35123701 PMCID: PMC8807182 DOI: 10.1016/j.jamda.2021.12.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 11/22/2022]
Affiliation(s)
- Paul R Katz
- Department of Geriatrics, Florida State University, College of Medicine, Tallahassee, FL, USA.
| | - Sarah Howd
- Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Casey Rust
- Department of Geriatrics, Florida State University, College of Medicine, Tallahassee, FL, USA
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McGilton KS, Bowers BJ, Resnick B. The Future Includes Nurse Practitioner Models of Care in the Long-Term Care Sector. J Am Med Dir Assoc 2022; 23:197-200. [PMID: 35123700 PMCID: PMC8807196 DOI: 10.1016/j.jamda.2021.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/25/2021] [Accepted: 12/03/2021] [Indexed: 10/27/2022]
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Meeks S, Degenholtz HB. Workforce Issues in Long-Term Care: Is There Hope for a Better Way Forward? THE GERONTOLOGIST 2021; 61:483-486. [PMID: 33757125 DOI: 10.1093/geront/gnab040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Suzanne Meeks
- Department of Psychological & Brain Sciences, University of Louisville, Kentucky, USA
| | - Howard B Degenholtz
- Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pennsylvania, USA
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Kozikowski A, Honda T, Segal-Gidan F, Hooker RS. Physician assistants in geriatric medical care. BMC Geriatr 2020; 20:449. [PMID: 33148193 PMCID: PMC7643446 DOI: 10.1186/s12877-020-01831-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/13/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The US population is maturing. As of 2020, over 52 million (16%) people are age 65 or older. With a citizenry that is increasingly "gray," the nation is short of medical providers who specialize in geriatric medical care. For example, the number of geriatrician physicians per 10,000 adults 65 years and older has decreased since 2000, with approximately 5300 in 2018. Nurse practitioners in geriatric medical care numbered 598 in 2018. Considering that the projected needs by 2030 will be over 30,000, the trajectory of geriatricians is becoming increasingly inadequate for the aging population. Physician assistants (PA) are another class of providers that are filling this geriatric medical care role, although little has been published. To address this role of PAs a study was undertaken. METHODS The National Commission on Certification of Physician Assistants databank provided the number and characteristics of PAs in geriatric medicine and compared them to all other certified PAs. Analyses included descriptive statistics, Chi-Square, and Wilcoxon Rank Sum tests for comparisons between PAs practicing in geriatric medical care vs. all other PA specialties. Where a comparison between PAs in geriatrics and other specialties was made, a P value of .05 or less was considered statistically significant. RESULTS As of 2018, there were 794 certified PAs, or 0.8% of the certified PA workforce, in geriatric medical care. This cadre has grown significantly since 2013, both in total number (increasing over 373%) and as a percentage of the PA workforce. The median age of certified PAs in geriatrics is 45 years, and 79% are female. Almost half (46%) of PAs in geriatric medicine work in extended care facilities or nursing homes, which differs from PAs in non-geriatric care. Another 8% work in government facilities and 8% in rehabilitation facilities. In 2018, the mean annual income for this PA group was $106,680. CONCLUSIONS As the American population continues to age, the relative growth of PAs in geriatric medicine makes them a natural part of the solution to the projected physician geriatrician deficit. The role of PAs in geriatric medical care remains to be explored.
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Affiliation(s)
- Andrzej Kozikowski
- National Commission on Certification of Physician Assistants, Johns Creek, GA, 30097, USA
| | - Trenton Honda
- Northeastern University, 202 Robinson Hall, 360 Huntington Avenue, Boston, MA, 02115, USA
| | - Freddi Segal-Gidan
- Departments of Neurology and Family Medicine, University of Southern California (USC) Keck School of Medicine, Los Angeles, CA, USA
- Neurobehavior & Alzheimer's Center and Rancho/USC California, Alzheimer's Disease Center at Rancho Los Amigos National, Rehabilitation Center in Downey, Downey, CA, USA
| | - Roderick S Hooker
- Northern Arizona University, 15917 NE Union Rd, Ridgeview, WA, 98642, USA.
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