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Talmage A, C Kunkel M, Kasler K, Keiser C, Akter N, Van Haitsma K, Abbott KM. "I think we just saw happier residents": nursing home provider reported readiness assessment of the individualized positive psychosocial interaction (IPPI) program. Aging Ment Health 2024:1-8. [PMID: 39262343 DOI: 10.1080/13607863.2024.2401960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 09/03/2024] [Indexed: 09/13/2024]
Abstract
OBJECTIVES This study assessed the readiness of The Individualized Positive Psychosocial Interaction (IPPI) program in the nursing home (NH) setting from the perspective of NH providers implementing the IPPI. The evidence-based IPPI program is designed to help remediate distress and improve mood for residents living with dementia. NH staff are trained to engage residents in brief (i.e. 10-min) one-to-one, preference-based activities to alleviate emotional distress and enhance quality of life. METHOD NH providers (n = 15) who championed the IPPI implementation completed an exit interview based on the nine domains of the Readiness Assessment for Pragmatic Trials (RAPT). Interviews were audio-recorded, transcribed, and coded by RAPT domains, then scored by the research team to reflect an average for each domain. RESULTS Providers rated the IPPI program's readiness high on the domains of alignment, impact, risk, implementation protocol, evidence, cost, and acceptability. The domains of measurement and feasibility scored lower, likely due to broader contextual issues and require particular attention. CONCLUSION Results illustrate that the IPPI program successfully aligns with stakeholder priorities, is a safe intervention with minimal risk, and has beneficial outcomes. The IPPI's low cost, design, and alignment with organizational goals also facilitated implementation while measuring outcomes and staffing considerations impacted organizational capacity for implementation.
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Affiliation(s)
- Alexis Talmage
- Department of Sociology and Gerontology, Miami University, Oxford, OH, USA
| | - Miranda C Kunkel
- Department of Sociology and Gerontology, Miami University, Oxford, OH, USA
| | - Kamryn Kasler
- Department of Sociology and Gerontology, Miami University, Oxford, OH, USA
| | - Cassie Keiser
- Department of Sociology and Gerontology, Miami University, Oxford, OH, USA
| | - Nahida Akter
- The Pennsylvania State University, Ross and Carol Nese College of Nursing, Program for Person Centered Living Systems of Care, University Park, PA, USA
| | - Kimberly Van Haitsma
- The Pennsylvania State University, Ross and Carol Nese College of Nursing, Program for Person Centered Living Systems of Care, University Park, PA, USA
- The Polisher Research Institute at Abramson Senior Care, Blue Bell, PA, USA
| | - Katherine M Abbott
- Department of Sociology and Gerontology, Miami University, Oxford, OH, USA
- Scripps Gerontology Center, Miami University, Oxford, OH, USA
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Plys E, Moss KO, Jacklin K, Yazzie M, Tambor E, Luers E, Elam L, Ahmad N, Kunicki ZJ, Malone C, Epstein-Lubow G. Discontinuing the Term "Stakeholder" From the NIA IMPACT Collaboratory Engaging Partners Team: An Example of the Process of Language Change in an Organization. Am J Geriatr Psychiatry 2024:S1064-7481(24)00442-1. [PMID: 39299872 DOI: 10.1016/j.jagp.2024.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/22/2024] [Accepted: 08/23/2024] [Indexed: 09/22/2024]
Abstract
In this paper, we describe our process of changing language of the National Institute on Aging Imbedded Pragmatic Alzheimer's disease and AD-related dementias Clinical Trials Collaboratory (NIA IMPACT Collaboratory) "Stakeholder Engagement Team" to "Engaging Partners Team" in response to feedback from community partners regarding the problematic connotations of the term "stakeholder." We present a brief history of the term "stakeholder" and its use in clinical and community-engaged research. Then, we summarize critiques of this term, including its colonial history and potential to reinforce complacency with generational traumas, particularly among Indigenous peoples and communities. We conclude with a detailed overview of our team and organization's multi-step process to discontinue use of the term "stakeholder," in alignment with a theoretical model of organizational behavior change. This paper highlights the importance of critically evaluating language and responding to community partners. We hope our process can guide other researchers and organizations.
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Affiliation(s)
- Evan Plys
- Center for Health Outcomes and Interdisciplinary Research (EP, NA), Massachusetts General Hospital, Boston, MA; Department of Psychiatry (EP), Harvard Medical School, Boston, MA.
| | - Karen O Moss
- College of Nursing (KOM), The Ohio State University, Columbus, OH
| | - Kristen Jacklin
- Department of Family Medicine and Biobehavioral Health (KJ), University of Minnesota Medical School, Minneapolis, MN; Memory Keepers Medical Discovery Team on Rural and American Indian Health Equity (KJ), University of Minnesota Duluth Medical School, Duluth, MN
| | - Molita Yazzie
- Indigenous Engagement (MY), National Institutes of Health, Bethesda, MD
| | - Ellen Tambor
- Education Development Center (ET, GEL), Waltham, MA
| | - Erin Luers
- Hinda and Arthur Marcus Institute for Aging Research (EL), Hebrew SeniorLife, Boston, MA
| | | | - Nina Ahmad
- Center for Health Outcomes and Interdisciplinary Research (EP, NA), Massachusetts General Hospital, Boston, MA
| | - Zachary J Kunicki
- Psychiatry and Human Behavior (ZJK, GEL), Warren Alpert Medical School of Brown University, Providence, RI
| | - Carolyn Malone
- Department of Health Services, Policy, and Practice (CM), Brown University, School of Public Health, Providence, RI
| | - Gary Epstein-Lubow
- Education Development Center (ET, GEL), Waltham, MA; Psychiatry and Human Behavior (ZJK, GEL), Warren Alpert Medical School of Brown University, Providence, RI
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Baker ZG, Dellapina M, Gustavson AM, Sefcik JS, Koeuth S, Gaugler JE, Van Haitsma K, Gitlin LN. Evidence Map of Non-Pharmacological Dementia Care Partner Interventions Implemented in the US: Gaps and Impact Opportunities. J Appl Gerontol 2024; 43:1259-1273. [PMID: 38629451 PMCID: PMC11321938 DOI: 10.1177/07334648241245527] [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] [Indexed: 08/16/2024] Open
Abstract
There are 200+ tested interventions for care partners (family, friends, and fictive kin) of people living with dementia (PLWD). But these interventions do not systematically cover relevant settings. Nor do these interventions affect all relevant outcomes that matter to people and healthcare systems. We present an evidence map of settings and outcomes from translated interventions to identify gaps. Of 190 studies identified, 31 unique interventions were retained in the evidence map. Identified setting gaps included studies set solely in hospitals/medical centers or set in multiple settings. Identified outcome gaps included interventions that improved care partner beliefs about providing care, care partner negative coping strategies, PLWD resources (e.g., social support), and PLWD coping strategies. Armed with an understanding of present gaps, we call on researchers to fill the identified gaps to ensure systematic coverage of settings and evaluation of outcomes that matter to people and healthcare systems.
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Affiliation(s)
- Zachary G. Baker
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | | | - Allison M. Gustavson
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Justine S. Sefcik
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
| | - Sokha Koeuth
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
| | - Joseph E. Gaugler
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Laura N. Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
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Unroe KT, Saliba D, Hickman SE, Zimmerman S, Levy C, Gurwitz J. Evaluation of medical therapies in the nursing home population: Gaps, challenges, and next steps. J Am Geriatr Soc 2024; 72:2951-2956. [PMID: 38485449 DOI: 10.1111/jgs.18829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 09/03/2024]
Affiliation(s)
- Kathleen T Unroe
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute Inc., Indianapolis, Indiana, USA
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Debra Saliba
- US Department of Veterans Affairs Greater Los Angeles Healthcare System (VAGLAS) Health Services Research and Development Service (HSR&D) Center of Innovation, Los Angeles, California, USA
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Anna and Harry Borun Center for Gerontological Research, University of California Division of Geriatrics, Los Angeles, California, USA
- RAND Corporation, Santa Monica, California, USA
| | - Susan E Hickman
- Indiana University Center for Aging Research, Regenstrief Institute Inc., Indianapolis, Indiana, USA
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Sheryl Zimmerman
- School of Social Work, University of North Carolina, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA
- Center for Excellence in Assisted Living (CEAL), School of Social Work, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Cari Levy
- Division of Geriatric Medicine, University of Colorado School of Medicine Anschutz Campus, Aurora, Colorado, USA
- Denver Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Jerry Gurwitz
- Division of Geriatric Medicine, UMass Chan Medical School, Worcester, Massachusetts, USA
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McHugh MC, Muschong KM, Bradley SM, Lo AX. Perspectives from persons living with dementia and their caregivers on emergency department visits, care transitions, and outpatient follow-up: A qualitative study. Acad Emerg Med 2024; 31:767-776. [PMID: 38590030 PMCID: PMC11335454 DOI: 10.1111/acem.14898] [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] [Received: 12/08/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Persons living with dementia (PLWD) experience frequent and costly emergency department (ED) visits, with poor outcomes attributed to suboptimal care and postdischarge care transitions. Yet, patient-centered data on ED care experiences and postdischarge needs are lacking. The objective of this study was to examine the facilitators and barriers to successful ED care and care transitions after discharge, according to PLWD and their caregivers. METHODS We conducted a qualitative study involving ED patients ages 65 and older with confirmed or suspected dementia and their caregivers. The semistructured interview protocol followed the National Quality Forum's ED Transitions of Care Framework and addressed ED care, care transitions, and outpatient follow-up care. Interviews were conducted during an ED visit at an urban, academic ED. Traditional thematic analysis was used to identify themes. RESULTS We interviewed 11 patients and 19 caregivers. Caregivers were more forthcoming than patients about facilitators and challenges experienced. Characteristics of the patients' condition (e.g., resistance to care, forgetfulness), the availability of family resources (e.g., caregiver availability, primary care access), and system-level factors (e.g., availability of timely appointments, hospital policies tailored to persons with dementia) served as facilitators and barriers to successful care. Some resources that would ameliorate care transition barriers could be easily provided in the ED, for example, offering clear discharge instructions and care coordination services and improving patient communication regarding disposition timeline. Other interventions would require investment from other parts of the health care system (e.g., respite for caregivers, broader insurance coverage). CONCLUSIONS ED care and care transitions for PLWD are suboptimal, and patient-level factors may exacerbate existing system-level deficiencies. Insight from patients and their caregivers may inform the development of ED interventions to design specialized care for this patient population. This qualitative study also demonstrated the feasibility of conducting ED-based studies on PLWD during their ED visit.
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Affiliation(s)
- Megan C McHugh
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kayla M Muschong
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sara M Bradley
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander X Lo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Boltz M, Van Haitsma K, Baier RR, Sefcik JS, Hodgson NA, Jao YL, Kolanowski A. Ready or Not: A Conceptual Model of Organizational Readiness for Embedded Pragmatic Dementia Research. Res Gerontol Nurs 2024; 17:149-160. [PMID: 38598780 PMCID: PMC11163963 DOI: 10.3928/19404921-20240403-02] [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: 04/12/2024]
Abstract
The National Institute on Aging Alzheimer's Disease/Alzheimer's Disease and Related Dementias Research Implementation Milestones emphasize the need for implementation research that maximizes up-take and scale-up of evidence-based dementia care practices across settings, diverse populations, and disease trajectories. Organizational readiness for implementation is a salient consideration when planning and conducting embedded pragmatic trials, in which interventions are implemented by provider staff. The current article examines the conceptual and theoretical underpinnings of organizational readiness for implementation and the operationalization of this construct. We offer a preliminary conceptual model for explicating and measuring organizational readiness and describe the unique characteristics and demands of implementing evidence-based interventions targeting persons with dementia and/or their care partners. [Research in Gerontological Nursing, 17(3), 149-160.].
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Harrison J, Mitchell SL, McCarthy EP, Mor V. The NIA IMPACT Collaboratory: History, impact, challenges, and the future of conducting ePCTs to improve dementia care. J Am Geriatr Soc 2024; 72:1608-1610. [PMID: 38362903 PMCID: PMC11090744 DOI: 10.1111/jgs.18803] [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: 12/12/2023] [Accepted: 12/27/2023] [Indexed: 02/17/2024]
Affiliation(s)
- Jill Harrison
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA
| | - Ellen P. McCarthy
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
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Hanson LC, Wessell K, Meeks N, Bennett AV, Toles M, Niznik J, Zimmerman S, Carpenter J, Ritchie CS, Ernecoff NC, Saliba D. Selecting outcomes for pragmatic clinical trials in dementia care: The IMPACT Collaboratory iLibrary. J Am Geriatr Soc 2024; 72:529-535. [PMID: 37916447 PMCID: PMC10922084 DOI: 10.1111/jgs.18644] [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: 09/23/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Many interventions improve care and outcomes for people with Alzheimer's Disease and related dementias (ADRD), yet are never disseminated. Pragmatic trials facilitate the adoption and dissemination of best practices, but gaps in pragmatic outcome measurement are a critical obstacle. Our objectives are (1) to describe the development and structure of the IMbedded Pragmatic ADRD Clinical Trials Collaboratory (IMPACT) iLibrary of potential outcome measures for ADRD pragmatic trials, and (2) to assess their pragmatic characteristics. METHODS We identified potential outcome measures from several sources: a database of administrative and clinical outcome measures from ADRD clinical trials registered in ClinicalTrials.gov, published reviews, and IMPACT pilot pragmatic trial outcome measures. The iLibrary reports (a) number of items, (b) completion time, (c) readability for diverse populations, (d) cost or copyright barriers to use, (e) method of administration, (f) assessor training burden, and (g) feasibility of data capture and interpretation in routine care; a summary of pragmatic characteristics of each outcome measure (high, moderate, low); items or descriptions of items; and links to primary citations regarding development or psychometric properties. RESULTS We included 140 outcome measures in the iLibrary: 66 administrative (100% were pragmatic) and 74 clinical (52% were pragmatic). The most commonly addressed outcome domains from administrative assessments included physical function, quality of care or communication concerns, and psychological symptoms or distress behaviors. The most commonly addressed outcome domains from clinical assessments were psychological symptoms or distress behaviors, physical function, cognitive function, and health-related quality of life. CONCLUSIONS Pragmatic outcome measures are brief, meaningful to diverse populations, easily scored and interpreted by clinicians, and available in electronic format for analysis. The iLibrary can facilitate the selection of measures for a wide range of outcomes relevant to people with ADRD and their care partners.
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Affiliation(s)
- Laura C. Hanson
- Division of Geriatric Medicine & Center for Aging and Health, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Kathryn Wessell
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Natalie Meeks
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Antonia V. Bennett
- Department of Health Policy and Management, University of North Carolina at Chapel Hill
| | - Mark Toles
- School of Nursing, University of North Carolina at Chapel Hill
| | - Josh Niznik
- Division of Geriatric Medicine & Center for Aging and Health, University of North Carolina at Chapel Hill
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
| | - Sheryl Zimmerman
- Schools of Social Work and Public Health, University of North Carolina at Chapel Hill
| | | | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School; Mongan Institute Center for Aging and Serious Illness, Boston
| | | | - Debra Saliba
- Borun Center, University of California, Los Angeles
- VA Geriatrics Research, Education and Clinical Center, Los Angeles
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Bennett AV, O'Brien K, Moreno M, Lanigan K, Maslow K, Malone CA, Hanson LC, Zimmerman S, Karlawish J, Largent EA, Aranda MP, Hinton L, Nicholson BP, Phillips L, Fazio S, Epstein-Lubow G. Development of a Lived Experience Panel to inform the design of embedded pragmatic trials of dementia care interventions. J Am Geriatr Soc 2024; 72:139-148. [PMID: 37787414 PMCID: PMC10841055 DOI: 10.1111/jgs.18621] [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: 04/26/2023] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND The National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's Disease and Alzheimer's Related Dementia Clinical Trials (IMPACT) Collaboratory convened a Lived Experience Panel (LEP) to inform the development of research priorities and provide input on conducting embedded pragmatic clinical trials (ePCTs) of dementia care interventions. Given the importance of people with lived experience to dementia research, and the unique considerations of engaging people with dementia, we report on our process for the recruitment, selection, and initial convening of the IMPACT LEP. METHODS The IMPACT Engaging Partners Team, in partnership with the Alzheimer's Association, sought nominations of individuals with mild cognitive impairment or early-stage dementia, care partners of other people living with dementia (PLWD), and proxy representatives for individuals with mid-to-late stage dementia. The 11-member LEP was composed of individuals with diverse personal experiences in part due to their age, race, ethnicity, gender, sexual orientation, geography, disability, or type of dementia. In its first year, the LEP met with IMPACT's Patient and Caregiver Relevant Outcomes Core and Ethics and Regulation Core. RESULTS LEP members provided valuable insights and nuanced discussion of issues relevant to ePCTs in dementia care from a broad range of personal experience. Panelists identified key research priorities and provided insight on outcomes often studied by researchers. The LEP also informed investigators' approaches to waivers and modifications of written informed consent and evaluation of minimal risk. Summary reports of the LEP meetings with each Core are available on the IMPACT website. At the end of the first year, changes were made to the composition of the LEP, and opportunities were identified for expanding panelist engagement with IMPACT investigators, as were priorities and scope for future input. CONCLUSIONS The IMPACT LEP provides a model for engaging PLWD and care partners in the research process as collaborators.
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Affiliation(s)
- Antonia V Bennett
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kyra O'Brien
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Monica Moreno
- Care and Support, Alzheimer's Association, Chicago, Illinois, USA
| | - Kerry Lanigan
- Care and Support, Alzheimer's Association, Chicago, Illinois, USA
| | - Katie Maslow
- The Gerontological Society of America, Washington, DC, USA
| | - Carolyn A Malone
- Department of Health Services, Policy, and Practice, Brown University, School of Public Health, Providence, Rhode Island, USA
| | - Laura C Hanson
- Division of Geriatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jason Karlawish
- Penn Memory Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Emily A Largent
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - María P Aranda
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
| | - Ladson Hinton
- Department of Psychiatry and Behavioral Sciences, University of California Davis, Davis, California, USA
| | - Brenda P Nicholson
- NIA IMPACT Engaging Partners Team, Emeritus, Providence, Rhode Island, USA
| | - Louise Phillips
- NIA IMPACT Engaging Partners Team, Emeritus, Providence, Rhode Island, USA
| | - Sam Fazio
- Quality Care and Psychosocial Research, Alzheimer's Association, Chicago, Illinois, USA
| | - Gary Epstein-Lubow
- Education Development Center, Waltham, Massachusetts, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Aranda MP, Baier R, Hinton L, Peak KD, Jackson JD, Dilworth-Anderson P, Gitlin LN, Jutkowitz E, Quiñones AR. Preparing for pragmatic trials in dementia care: Health equity considerations for nonpharmacological interventions. J Am Geriatr Soc 2023; 71:3874-3885. [PMID: 37656062 PMCID: PMC10841288 DOI: 10.1111/jgs.18568] [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: 01/10/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 09/02/2023]
Abstract
Inequities with regard to brain health, economic costs, and the evidence base for dementia care continue. Achieving health equity in dementia care requires rigorous efforts that ensure disproportionately affected populations participate fully in-and benefit from-clinical research. Embedding-proven interventions under real-world conditions and within existing healthcare systems have the potential to examine the effectiveness of an intervention, improve dementia care, and leverage the use of existing resources. Developing embedded pragmatic controlled trials (ePCT) research designs for nonpharmacological dementia care interventions involves a plethora of a priori assumptions and decisions. Although frameworks exist to determine whether interventions are "ready" for ePCT, there is no heuristic to assess health equity-readiness. We discuss health equity considerations, case examples, and research strategies across ePCT study domains of evidence, risk, and alignment. Future discussions regarding health equity considerations across other domains are needed.
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Affiliation(s)
- María P Aranda
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, Los Angeles, California, USA
- Edward R. Roybal Institute on Aging, University of Southern California, Los Angeles, California, USA
| | - Rosa Baier
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Ladson Hinton
- Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, California, USA
| | - Katherine D Peak
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Jonathan D Jackson
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peggye Dilworth-Anderson
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laura N Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania, USA
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
- Center of Innovation in Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Eric Jutkowitz
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
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Lech S, Gellert P, Spang RP, Voigt-Antons JN, Huscher D, O'Sullivan JL, Schuster J. Effectiveness of a tablet-based intervention for people living with dementia in primary care-A cluster randomized controlled trial. Int J Geriatr Psychiatry 2023; 38:e6035. [PMID: 38038608 DOI: 10.1002/gps.6035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/18/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Primary care physicians (PCP) play a key role in the care of people living with dementia. However, the implementation and practicability of the German S3 Dementia Guideline in primary care remain unclear. The main objective of the present study was to evaluate an intervention for improving guideline-based dementia care in primary care. DESIGN A two-arm, 9-month follow-up cluster-randomized controlled trial with two parallel groups. SETTING 28 primary care practices in Berlin and the surrounding area in Germany. PARTICIPANTS A total of N = 28 PCP, N = 91 people living with dementia, and N = 88 informal caregivers participated in the trial. INTERVENTION A tablet-based intervention to improve adherence to the German S3 Dementia Guideline in primary care was compared to a control group (care as usual plus a handbook on dementia). MeasurementsAdherence to dementia guideline (primary outcome) was measured on PCP' (23 items) and informal caregivers' level (19 items) with a self-developed checklist. Secondary outcomes (quality of life, neuropsychiatric symptoms, activities of daily living, general health status, depression, and caregiver burden) were measured with standardized assessments. Also, post-hoc per-protocol analyses were conducted. RESULTS No differences in guideline adherence between the intervention and the control group were observed. Further, no significant impact of the intervention on secondary outcomes was detected. CONCLUSION The DemTab Study did not improve self-reported guideline adherence in PCP. However, important implementation barriers such as lack of interoperability and low applicability of existing German S3 Dementia Guideline in the primary care setting were identified and are being discussed. TRIAL REGISTRATION The DemTab trial was prospectively registered with the ISRCTN registry (Trial registration number: ISRCTN15854413). Registered 01 April 2019, https://doi.org/10.1186/ISRCTN15854413.
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Affiliation(s)
- Sonia Lech
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute for Medical Sociology and Rehabilitation Science, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Psychiatry and Psychotherapy, Berlin, Germany
| | - Paul Gellert
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute for Medical Sociology and Rehabilitation Science, Berlin, Germany
| | - Robert P Spang
- Technische Universität Berlin, Quality and Usability Lab, Berlin, Germany
| | - Jan-Niklas Voigt-Antons
- Immersive Reality Lab, University of Applied Sciences Hamm-Lippstadt, Lippstadt, Germany
- Deutsches Forschungszentrum für Künstliche Intelligenz GmbH (DFKI), Speech and Language Technology, Berlin, Germany
| | - Dörte Huscher
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, and Berlin Institute of Health, Berlin, Germany
| | - Julie L O'Sullivan
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute for Medical Sociology and Rehabilitation Science, Berlin, Germany
| | - Johanna Schuster
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute for Medical Sociology and Rehabilitation Science, Berlin, Germany
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12
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Fortinsky RH, Shugrue N, Robison JT, Gitlin LN. The Case for Conducting Pragmatic Dementia Care Trials in Medicaid Home and Community-Based Service Settings. J Am Med Dir Assoc 2023; 24:1918-1923. [PMID: 37918816 PMCID: PMC10795107 DOI: 10.1016/j.jamda.2023.09.026] [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: 01/30/2023] [Revised: 07/10/2023] [Accepted: 09/18/2023] [Indexed: 11/04/2023]
Abstract
Medicaid-funded home and community-based services (HCBSs) reach large numbers of individuals living with dementia who would otherwise reside in nursing homes with Medicaid funding. Medicaid HCBSs also often augment care provided by family and other informal caregivers to individuals living with dementia. Although Medicaid-funded HCBSs are offered in most states in lieu of nursing home care, they have been largely overlooked as health care system partners for implementation and testing of evidence-based dementia care interventions using embedded pragmatic clinical trial (ePCT) designs. In this article, we make the case for the importance of Medicaid-funded HCBSs as dementia care ePCT partners because of the volume of vulnerable clients with dementia served and the potential positive impacts that evidence-based dementia care programs can have on clients and their informal caregivers. This article first characterizes the Medicaid HCBS setting in terms of populations served and organizational arrangements across states. We then characterize strengths and potential limitations presented by Medicaid HCBSs as settings within which to implement dementia care ePCTs, using as a conceptual framework the Pragmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool and its domains. We draw on our experiences implementing the Care of Persons with Dementia in their Environments (COPE) program in a statewide Medicaid HCBS setting to highlight how these potential ePCT partners can help optimize pragmatic approaches to several PRECIS-2 domains. We found that partners are especially effective in implementing pragmatic ways to determine eligibility for evidence-based dementia care programs; assist with recruitment of eligible individuals; incorporate dementia care interventions into the range of existing HCBSs; and track outcomes relevant to persons living with dementia, caregivers, HCBS providers, and Medicaid insurance stakeholders. We conclude with recommendations for researchers, potential ePCT partners, and policymakers to help facilitate the growth of dementia care ePCTs in Medicaid HCBS settings across the United States.
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Affiliation(s)
| | - Noreen Shugrue
- UConn Center on Aging, University of Connecticut, Farmington, CT, USA
| | - Julie T Robison
- UConn Center on Aging, University of Connecticut, Farmington, CT, USA
| | - Laura N Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
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13
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Teno JM, Hanson LC, Lima JC, Saliba D. Protecting seriously ill populations during pragmatic clinical trials. J Am Geriatr Soc 2023; 71:2290-2296. [PMID: 36949574 PMCID: PMC10363207 DOI: 10.1111/jgs.18333] [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] [Received: 03/02/2022] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 03/24/2023]
Abstract
Pragmatic clinical trials (PCTs) emphasize real-world effectiveness methodology to address the limitations of results from explanatory randomized clinical trials (RCTs), which often fail to translate to real-world medical practice. An inherent tension in the conduct of PCTs is that the research must impose a minimal burden on patients and health care institutions. PCTs prioritize outcome measures from existing data sources to minimize data collection burden; however, a lack of patient-reported outcomes may result in gaps in safety for vulnerable populations, such as those with serious illnesses. One proposed standard for judging the readiness of a study for a pragmatic trial is a ranking system that assigns PCTs a lower rank if they impose additional data collection burdens. However, this results in the wide use of measures of health care utilization and costs while patient experience measures, which could capture adverse unintended consequences, are omitted. In this article, we make the case for a risk-based approach to imposing additional data collection in PCTs to capture potential safety and patient experience outcomes, using examples from "real life" implemented interventions to improve end-of-life care through the Liverpool Pathway and through the implementation of Physician Orders for Life Sustaining Treatment (POLST) in Oregon.
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Affiliation(s)
- Joan M Teno
- Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, UNC Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Julie C Lima
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Debra Saliba
- UCLA Borun Center and the Los Angeles VA Geriatrics Research and Clinical Center (GRECC), RAND Health, Los Angeles, California, USA
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14
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Mitchell S, McCarthy E, Hinton L, Nkimbeng M, Peak KD, Quiñones AR. Best Practice Recommendations for Integrating Health Equity into Pragmatic Clinical Trials for Dementia Care. Ethn Dis 2023; 33:84-90. [PMID: 38845735 PMCID: PMC11145731 DOI: 10.18865/ed.33.2-3.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Context Minoritized populations experience higher rates of dementia and worse health outcomes than non-Hispanic white people, but they are vastly underrepresented in pragmatic clinical trials embedded in health care systems (ePCTs). Little guidance is available to consider health equity-relevant issues in ePCTs. Objective This report describes the development, structure, and content of a guidance document developed by the National Institute on Aging Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory to help investigators systematically assess the integration of health equity into all aspects of ePCT design. Design Led by a task force of IMPACT investigators, a literature review of existing frameworks for health equity considerations in clinical trials was conducted. Next, priority health equity-relevant recommendations in the domains of ePCT design were solicited from Collaboratory experts. The 50 submitted recommendations were reduced to 36 nonoverlapping best practices and categorized into 6 domains, as follows: Getting Started, Community Stakeholder Engagement, Design and Analysis, Intervention Design and Implementation, Health Care System and Participant Selection, and Selecting Outcomes. Each domain had 6 best practice recommendations consisting of a succinctly worded main sentence, with 1 to 2 explanatory sentences. The content was finalized through an iterative process of editing and revision. Conclusions Although specifically focused on ePCTs involving dementia care, the best practices are applicable to any ePCT and can be useful to advance health equity in traditional clinical trials. This guidance document provides a first step toward promoting holistic, structured integration of health equity into the design and conduct of ePCTs as a matter of good science.
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15
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Niznik JD, Ernecoff NC, Thorpe CT, Mitchell SL, Hanson LC. Operationalizing deprescribing as a component of goal-concordant dementia care. J Am Geriatr Soc 2023; 71:1340-1344. [PMID: 36550635 PMCID: PMC10089936 DOI: 10.1111/jgs.18190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Natalie C Ernecoff
- RAND Corporation, Pittsburgh, Pennsylvania, USA
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Susan L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
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16
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Baker ZG, Nkimbeng M, Cuevas PEG, Quiñones AR, Kaur Kang H, Gaugler JE, Hinton L, Gitlin LN, Shippee TP. Simultaneously Developing Interventions for Low-/Middle-Income and High-Income Settings: Considerations and Opportunities. THE GERONTOLOGIST 2023; 63:568-576. [PMID: 35679613 PMCID: PMC10028230 DOI: 10.1093/geront/gnac079] [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: 03/24/2022] [Indexed: 11/14/2022] Open
Abstract
Most older adults reside in low- and middle-income countries (LMICs) but most research dollars spent on interventions to improve the lives of older adults are awarded to researchers in high-income countries (HICs). One approach to improve the implementation of evidence-based innovations for older adults in LMICs is designing interventions that are relevant to LMICs and HICs simultaneously. We propose that researchers in HICs could partner with stakeholders in an LMIC throughout the intervention design process to better position their intervention for the implementation in that LMIC. We provide an example study from an adaptation of the Resources for Enhancing Caregiver Health II in Vietnam, which did not use this strategy but may have benefited from this strategy. We then turn to several considerations that are important for researchers to contemplate when incorporating this strategy. Finally, we explore incentives for creating interventions that are relevant to both HICs and LMICs for funders, intervention designers, and intervention receivers. Although this is not the only strategy to bring interventions to LMICs, it may represent another tool in researchers' toolboxes to help expedite the implementation of efficacious interventions in LMICs.
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Affiliation(s)
- Zachary G Baker
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Manka Nkimbeng
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pearl Ed G Cuevas
- School of Nursing, Centro Escolar University, San Miguel, Manila, Philippines
| | - Ana R Quiñones
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Harmeet Kaur Kang
- Chitkara School of Health Sciences, Chitkara University, Punjab, India
| | - Joseph E Gaugler
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ladson Hinton
- Department of Psychiatry and Behavioral Sciences, University of California―Davis, Sacramento, California, USA
| | - Laura N Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania, USA
| | - Tetyana P Shippee
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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17
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Nix HP, Largent EA, Taljaard M, Mitchell SL, Weijer C. Ethical analysis of vulnerabilities in cluster randomized trials involving people living with dementia in long-term care homes. J Am Geriatr Soc 2023; 71:588-598. [PMID: 36435175 PMCID: PMC9957897 DOI: 10.1111/jgs.18128] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/27/2022] [Accepted: 10/29/2022] [Indexed: 11/28/2022]
Abstract
Cluster randomized trials (CRT) of non-pharmacological interventions are an important means of improving the quality of care and quality of life of people living with dementia (PLWD) in long-term care (LTC) homes. PLWD in LTC homes are, however, vulnerable in manifold ways. Therefore, researchers require guidance to ensure that the rights and welfare of PLWD are protected in the course of this valuable research. In this article, we introduce a framework for identifying vulnerabilities in randomized trials and apply it to three CRTs involving PLWD in LTC homes. CRTs may render PLWD in LTC homes vulnerable to three autonomy wrongs: inadequately informed consent, inadequately voluntary consent, and invasions of privacy; two welfare wrongs: risks of therapeutic procedure exceed potential benefits, and excessive risk of non-therapeutic procedures; and one justice wrong: unjust impact of research activities on care. We then discuss appropriate, feasible additional protections that can be implemented to mitigate vulnerability while preserving the scientific validity of the CRT. Corresponding additional protections that can be feasibly implemented include capacity assessments, substitute decision-makers, assent, insulation from LTC home employees during the consent process, patient advocates, utilizing LTC home employees for data collection, stakeholder engagement, additional supervision during study procedures, using caregivers to complete questionnaires by proxy, and gatekeeper permission. Reassuringly, many of these additional protections promote, rather than imperil, the scientific validity of these trials.
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Affiliation(s)
- Hayden P Nix
- Schulich School of Medicine & Dentistry, Western University, London, Canada
- Oxford Uehiro Center for Practical Ethics, Oxford University, Oxford, UK
| | - Emily A Largent
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Charles Weijer
- Department of Medicine, Western University, London, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Canada
- Department of Philosophy, Western University, London, Canada
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18
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Nicholls SG, Al‐Jaishi AA, Niznick H, Carroll K, Madani MT, Peak KD, Madani L, Nevins P, Adisso L, Li F, Weijer C, Mitchell SL, Welch V, Quiñones AR, Taljaard M. Health equity considerations in pragmatic trials in Alzheimer's and dementia disease: Results from a methodological review. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2023; 15:e12392. [PMID: 36777091 PMCID: PMC9899766 DOI: 10.1002/dad2.12392] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/20/2022] [Accepted: 12/06/2022] [Indexed: 02/07/2023]
Abstract
Introduction To improve dementia care delivery for persons across all backgrounds, it is imperative that health equity is integrated into pragmatic trials. Methods We reviewed 62 pragmatic trials of people with dementia published 2014 to 2019. We assessed health equity in the objectives; design, conduct, analysis; and reporting using PROGRESS-Plus which stands for Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, and other factors such as age and disability. Results Two (3.2%) trials incorporated equity considerations into their objectives; nine (14.5%) engaged with communities; 4 (6.5%) described steps to increase enrollment from equity-relevant groups. Almost all trials (59, 95.2%) assessed baseline balance for at least one PROGRESS-Plus characteristic, but only 10 (16.1%) presented subgroup analyses across such characteristics. Differential recruitment, attrition, implementation, adherence, and applicability across PROGRESS-Plus were seldom discussed. Discussion Ongoing and future pragmatic trials should more rigorously integrate equity considerations in their design, conduct, and reporting. Highlights Few pragmatic trials are explicitly designed to inform equity-relevant objectives.Few pragmatic trials take steps to increase enrollment from equity-relevant groups.Disaggregated results across equity-relevant groups are seldom reported.Adherence to existing tools (e.g., IMPACT Best Practices, CONSORT-Equity) is key.
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Affiliation(s)
- Stuart G. Nicholls
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Ahmed A. Al‐Jaishi
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Harrison Niznick
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Kelly Carroll
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | | | - Katherine D. Peak
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Leen Madani
- Bruyère Research Institute and, University of OttawaOttawaOntarioCanada
| | - Pascale Nevins
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Lionel Adisso
- VITAM – Centre de recherche en santé durableDepartment of Social and Preventive MedicineFaculty of MedicineUniversité LavalQuebecCanada
| | - Fan Li
- Department of BiostatisticsYale University School of Public HealthNew HavenConnecticutUSA
| | - Charles Weijer
- Departments of MedicineEpidemiology & Biostatistics, and PhilosophyWestern UniversityLondonOntarioCanada
| | - Susan L. Mitchell
- Hebrew SeniorLife, Marcus Institute for Aging ResearchBostonMassachusettsUSA
| | - Vivian Welch
- Bruyère Research Institute andSchool of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada
| | - Ana R. Quiñones
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Monica Taljaard
- Clinical Epidemiology ProgramOttawa Hospital Research Institute andSchool of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada
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19
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Ball DE, Mattke S, Frank L, Murray JF, Noritake R, MacLeod T, Benham‐Hermetz S, Kurzman A, Ferrell P. A framework for addressing Alzheimer's disease: Without a frame, the work has no aim. Alzheimers Dement 2022; 19:1568-1578. [PMID: 36478657 DOI: 10.1002/alz.12869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/07/2022] [Accepted: 10/17/2022] [Indexed: 12/13/2022]
Abstract
Confronting Alzheimer's disease (AD) involves patients, healthcare professionals, supportive services, caregivers, and government agencies interacting along a continuum from initial awareness to diagnosis, treatment, support, and care. This complex scope presents a challenge for health system transformation supporting individuals at risk for, or diagnosed with, AD. The AD systems preparedness framework was developed to help health systems identify specific opportunities to implement and evaluate focused improvement programs. The framework is purposely flexible to permit local adaptation across different health systems and countries. Health systems can develop solutions tailored to system-specific priorities considered within the context of the overall framework. Example metric concepts and initiatives are provided for each of ten areas of focus. Examples of funded projects focusing on screening and early detection are provided. It is our hope that stakeholders utilize the common framework to generate and share additional implementation evidence to benefit individuals with AD.
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Affiliation(s)
- Daniel E. Ball
- Davos Alzheimer's Collaborative Philadelphia Pennsylvania USA
| | - Soeren Mattke
- Center for Economic and Social Research University of Southern California Los Angeles California USA
| | - Lori Frank
- The New York Academy of Medicine New York New York USA
| | - James F. Murray
- Davos Alzheimer's Collaborative Philadelphia Pennsylvania USA
| | - Ryoji Noritake
- Health and Global Policy Institute, Grand Cube 3F, Otemachi Financial City Global Business Hub Tokyo Tokyo Japan
| | - Timothy MacLeod
- Davos Alzheimer's Collaborative Philadelphia Pennsylvania USA
- Bridgeable Toronto Ontario USA
| | | | - Alissa Kurzman
- Davos Alzheimer's Collaborative Philadelphia Pennsylvania USA
- High Lantern Group Philadelphia Pennsylvania USA
- World Economic Forum New York New York USA
| | - Phyllis Ferrell
- Davos Alzheimer's Collaborative Philadelphia Pennsylvania USA
- Eli Lilly and Company Lilly Corporate Center Indianapolis Indiana USA
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20
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Travers JL, Wittenberg GF, Gifford DR, Reddy A, McLaughlin MM, Baier RR. Providers' Perspectives on High-Quality Dementia Care in Long-Term Care. J Am Med Dir Assoc 2022; 23:2030.e1-2030.e8. [PMID: 36058295 PMCID: PMC11307288 DOI: 10.1016/j.jamda.2022.07.025] [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: 04/14/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To understand dementia care providers' perspectives on high-quality care for persons living with dementia (PLWD) in long-term care (LTC). DESIGN A qualitative study using a directed content analysis approach. SETTING AND PARTICIPANTS Nine national LTC dementia care providers. METHODS We facilitated 5 listening sessions centered around dementia care philosophies, models, and practices. Two researchers first mapped qualitative data to the Holistic Approach to Transformational Change (HATCh) model for dementia care using a directed content analysis approach. They then identified themes and subthemes emerging from the data using a conventional analysis approach. They coded data iteratively and solicited input from 3 additional researchers to reach consensus where needed. Member checks were performed to ensure the trustworthiness of the data during 2 follow-up listening sessions. RESULTS The 9 participants described the importance of understanding the experiences of PLWDs in order to provide high-quality dementia care and to deliver such care with the residents and their preferences as the focus. They emphasized experiential education as essential for families and all staff, regardless of role. They noted the need to balance safety with resident choice, as well as the corresponding need for facility leadership and regulators to support such choices. The listening sessions revealed areas to foster person-centered care for PLWD, but also highlighted barriers to implementing this philosophy in LTC settings. CONCLUSIONS AND IMPLICATIONS Emergent themes included care practices that center on resident preferences and are supported by staff with the experiential education and communication skills necessary to relate to and support PLWD. These findings provide contextual information for researchers seeking to identify and test interventions that reflect LTC providers' priorities for PLWD and emphasize the need to align research priorities with provider priorities.
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Affiliation(s)
- Jasmine L Travers
- Rory Meyers College of Nursing, New York University, New York, NY, USA.
| | - Grace F Wittenberg
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA
| | - David R Gifford
- American Health Care Association/National Center for Assisted Living, Washington, DC, USA
| | - Ann Reddy
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA
| | - Marguerite M McLaughlin
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA
| | - Rosa R Baier
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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21
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Hickman SE, Mitchell SL, Hanson LC, Tu W, Stump TE, Unroe KT. The design and conduct of a pragmatic cluster randomized trial of an advance care planning program for nursing home residents with dementia. Clin Trials 2022; 19:623-635. [PMID: 35815777 PMCID: PMC9691516 DOI: 10.1177/17407745221108992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS A significant number of people with Alzheimer's disease or related dementia diagnoses will be cared for in nursing homes near the end of life. Advance care planning (ACP), the process of eliciting and documenting patient-centered preferences for care, is considered essential to providing high quality care for this population. Nursing homes are currently required by regulations to offer ACP to residents and families, but no training requirements exist for nursing home staff, and approaches to fulfilling this regulatory and ethical responsibility vary. As a result, residents may receive care inconsistent with their goals, such as unwanted hospitalizations. Pragmatic trials offer a way to develop and test ACP in real-world settings to increase the likelihood of adoption of sustainable best practices. METHODS The "Aligning Patient Preferences-a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support (APPROACHES)" project is designed to pragmatically test and evaluate a staff-led program in 137 nursing homes (68 = intervention, 69 = control) owned by two nursing home corporations. Existing nursing home staff receive standardized training and implement the ACP Specialist program under the supervision of a corporate lead. The primary trial outcome is the annual rate of hospital transfers (admissions and emergency department visits). Consistent with the spirit of a pragmatic trial, study outcomes rely on data already collected for quality improvement, clinical, or billing purposes. Configurational analysis will also be performed to identify conditions associated with implementation. RESULTS Partnerships with large corporate companies enable the APPROACHES trial to rely on corporate infrastructure to roll out the intervention, with support for a corporate implementation lead who is charged with the initial introduction and ongoing support for nursing home-based ACP Specialists. These internal champions connect the project with other company priorities and use strategies familiar to nursing home leaders for the initiation of other programs. Standardized data collection across nursing homes also supports the conduct of pragmatic trials in this setting. DISCUSSION Many interventions to improve care in nursing homes have failed to demonstrate an impact or, if successful, maintain an impact over time. Pragmatic trials, designed to test interventions in real-world contexts that are evaluated through existing data sources collected routinely as part of clinical care, are well suited for the nursing home environment. A robust program that increases access to ACP for nursing home residents has the potential to increase goal-concordant care and is expected to reduce hospital transfers. If successful, the ACP Specialist Program will be primed for rapid translation into nursing home practice to reduce unwanted, burdensome hospitalizations and improve the quality of care for residents with dementia.
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Affiliation(s)
- Susan E Hickman
- School of Nursing, Indiana University, Indianapolis,
Indiana, U.S.,RESPECT (Research in Palliative and End-of-Life
Communication and Training) Signature Center, Indiana University Purdue University
Indianapolis, Indianapolis, Indiana, U.S.,Division of General Internal Medicine and Geriatrics, Department of Medicine, School of Medicine, Indiana University, Indiana, U.S.,IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S
| | - Susan L Mitchell
- Harvard Medical School, Boston, Massachusetts, U.S.,Beth Israel Deaconess Medical Center, Boston,
Massachusetts, U.S.,Marcus Institute for Aging Research, Boston, Massachusetts,
U.S
| | - Laura C Hanson
- School of Medicine, University of North Carolina, Chapel Hill,
North Carolina
| | - Wanzhu Tu
- IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S.,Department of Biostatistics & Health Data ScienceS, School of Medicine,
Indiana University, Indiana, U.S
| | - Timothy E Stump
- Department of Biostatistics & Health Data ScienceS, School of Medicine,
Indiana University, Indiana, U.S
| | - Kathleen T Unroe
- RESPECT (Research in Palliative and End-of-Life
Communication and Training) Signature Center, Indiana University Purdue University
Indianapolis, Indianapolis, Indiana, U.S.,Division of General Internal Medicine and Geriatrics, Department of Medicine, School of Medicine, Indiana University, Indiana, U.S.,IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S
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22
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Schara H, Johnson T, Brungardt A, Marcus AM, Cassidy J, Shanbhag P, Plys E, Lum HD. Living With Dementia: Care Partner Needs and Outcomes of a Dementia Support Program in Primary Care. Gerontol Geriatr Med 2022; 8:23337214221129466. [PMID: 36275412 PMCID: PMC9583199 DOI: 10.1177/23337214221129466] [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: 07/29/2022] [Revised: 09/12/2022] [Accepted: 09/12/2022] [Indexed: 11/17/2022] Open
Abstract
To address the need for collaborative approaches to managing dementia in primary care, we implemented the Living with Dementia (LWD) program in a geriatric primary care clinic. This study evaluated the impact of short (≤6 months) and longer-term (7+ months) participation in LWD on care partner outcomes (i.e., self-efficacy, depression, and burden) using t-tests and examined dementia support topics discussed with care partners through the intervention using deductive content analysis. Across 20 months analyzed, 57 dyads participated in the LWD program. Short and longer-term LWD participation indicated a significant increase in self-efficacy with small effect sizes; no changes were observed in depression or burden. Dementia support topics most frequently discussed with care partners focused on care partner well-being, behavior management, and offering referrals. This early evaluation suggests a collaborative care program integrated into primary care can address needs related to caring for persons with dementia and may improve care partner self-efficacy.
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Affiliation(s)
- Hannah Schara
- University of Colorado School of
Medicine, Aurora, USA
| | | | | | | | | | | | - Evan Plys
- University of Colorado School of
Medicine, Aurora, USA
| | - Hillary D. Lum
- University of Colorado School of
Medicine, Aurora, USA,Hillary D. Lum, MD, PhD, Division of
Geriatric Medicine, Department of Medicine, University of Colorado School of
Medicine, 12631 East 17th Avenue, Mailstop B179, Aurora, CO 80045, USA.
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23
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Parchman ML, Perloff J, Ritter G. Can clinician champions reduce potentially inappropriate medications in people living with dementia? Study protocol for a cluster randomized trial. Implement Sci 2022; 17:63. [PMID: 36163181 PMCID: PMC9513870 DOI: 10.1186/s13012-022-01237-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For people living with dementia (PLWD) the overuse of potentially inappropriate medications (PIMs) remains a persistent problem. De-prescribing trials in the elderly have mixed results. Clinician champions may be uniquely suited to lead efforts to address this challenge. Here we describe the study protocol for a 24-month embedded pragmatic cluster-randomized clinical trial within two accountable care organizations (ACOs) of such a clinician champion intervention. The specific aims are to (1) assess the effectiveness of a clinician champion on de-implementing PIMs in PLWD, (2) determine if the intervention is associated with a reduction in emergency department (ED) visits and hospitalizations attributed to a fall, and (3) examine five implementation outcomes: appropriateness, feasibility, fidelity, penetration, and equity. METHODS/DESIGN Two ACOs agreed to participate: United States Medical Management (USMM) and Oschner Health System. The unit of randomization will be the primary care clinic. A clinician champion will be recruited from each of the intervention clinics to participate in a 6-month training program and then work with clinicians and staff in their clinic for 12 months to reduce the use of PIMs in their PLWD population. For aims 1 and 2, Medicare claims data will be used to assess outcomes. The outcome for aim #1 will be medication possession rates per quarter, for the three therapeutic classes of PIMs among patients with dementia in intervention clinics versus control clinics. For aim #2, we will assess the incidence of falls using a previously validated algorithm. For both aims 1 and 2, we will construct hierarchical models with time period observations nested within patient using generalized estimating equations (GEE) with robust standard errors. The key variable of interest will be the treatment indicator assigned based on practice. For aim #3, we will conduct qualitative thematic analysis of documentation by the clinician champions in their project workbooks to evaluate the five implementation outcomes. DISCUSSION This embedded pragmatic trial will add to our existing knowledge regarding the effectiveness of a clinician champion strategy to de-prescribe potentially inappropriate medication among patients with dementia as well as its appropriateness, feasibility, fidelity, penetration, and equity. TRIAL REGISTRATION Clinicaltrials.gov NCT05359679 , Registered May 4, 2022.
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Affiliation(s)
- Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.
| | - Jennifer Perloff
- Brandeis University, Waltham, MA, USA
- Institute for Accountable Care, Washington, DC, USA
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24
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Nkimbeng M, Han HR, Szanton SL, Alexander KA, Davey-Rothwell M, Giger JT, Gitlin LN, Joo JH, Koeuth S, Marx KA, Mingo CA, Samuel LJ, Taylor JL, Wenzel J, Parisi JM. Exploring Challenges and Strategies in Partnering With Community-Based Organizations to Advance Intervention Development and Implementation With Older Adults. THE GERONTOLOGIST 2022; 62:1104-1111. [PMID: 34958098 PMCID: PMC9451017 DOI: 10.1093/geront/gnab190] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Indexed: 12/30/2022] Open
Abstract
Minoritized older adults face multiple health inequities and disparities, but are less likely to benefit from evidence-based health care interventions. With the increasing diversity of the U.S. aging population, there is a great promise for gerontology researchers to partner with racial/ethnic minority organizations and underrepresented communities to develop and implement evidence-based health interventions. Community-Based Participatory Research and Implementation Science offer guidance and strategies for researchers to develop and sustain community partnerships. However, researchers partnering with community organizations continue to face challenges in these collaborations, study outcomes, and sustainability. This may be especially true for those junior in their career trajectory or new to community-engaged research. The purpose of this forum article is to detail critical challenges that can affect gerontology researcher-community partnerships and relationships from the perspective of researchers. Seven challenges (pre- or mid-intervention design, implementation, and postimplementation phases) described within the Equity-focused Implementation Research for health programs framework are identified and discussed. Potential solutions are also presented. Planning for potential obstacles of the researcher-community partnerships can inform innovative solutions that will facilitate successful partnerships, thereby promoting the advancement of collaborative research between academic institutions and community organizations to improve older adult health outcomes.
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Affiliation(s)
- Manka Nkimbeng
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Hae-Ra Han
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sarah L Szanton
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| | | | - Melissa Davey-Rothwell
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jarod T Giger
- University of Kentucky College of Social Work, Lexington, Kentucky, USA
| | - Laura N Gitlin
- Drexel University, College of Nursing and Health Professions, Philadelphia, Pennsylvania, USA
| | - Jin Hui Joo
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sokha Koeuth
- Drexel University, College of Nursing and Health Professions, Philadelphia, Pennsylvania, USA
| | - Katherine A Marx
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Chivon A Mingo
- Georgia State University, College of Arts & Sciences, Atlanta, Georgia, USA
| | - Laura J Samuel
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Janiece L Taylor
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer Wenzel
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeanine M Parisi
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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25
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Kolanowski A, Heid AR, Behrens L, Riley K, Madrigal C, Boltz M, Van Haitsma K, Resnick B, Galik E, Ellis J, Eshraghi K. Community Goal Setting and Attainment: Organizational Characteristics and Indicators of Staff Adoption. J Gerontol Nurs 2022; 48:5-12. [PMID: 35511062 DOI: 10.3928/00989134-20220404-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In residential care communities (CCs), implementation strategies can improve the use of person-centered approaches for residents' behavioral symptoms of distress. We examined staff perceptions of how well their organizational goals for achieving person-centered care (PCC) were met following implementation of the strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Distress. We also identified organizational characteristics and indicators of staff adoption associated with perceived goal attainment. Goal attainment was evaluated by staff using goal attainment scaling (GAS) at the completion of the implementation trial in 26 CCs. Correlations, t tests, and linear regression were used to determine which factors were associated with goal attainment. Total time spent with the research facilitator, stable staff group membership, and presence of a survey deficiency during the study period explained 63% of the variance in goal attainment. Staff can set achievable organizational goals to improve PCC for residents' behavioral symptoms of distress. [Journal of Gerontological Nursing, 48(5), 5-12.].
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26
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Heid AR, Abbott KM, Rovine MJ, Eshraghi K, Madrigal C, Crumbie V, Van Haitsma K. The Stability of Nursing Home Residents' Ratings of Importance of Recreation Preferences Over One Year. J Appl Gerontol 2022; 41:1942-1951. [PMID: 35506670 DOI: 10.1177/07334648221089239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Long-term stability of nursing home (NH) residents' everyday preference remains unknown. We examined 1-year stability in reports of importance of 34-recreational activity preferences (8-MDS 3.0 Section F items; 26-Preferences for Everyday Living Inventory-NH items) by NH residents (N = 161). We examined mean differences on demographic and clinical characteristics of residents for preferences showing change. Importance ratings of preferences were highly stable over 1-year, with 91% of items retaining the same valence of importance for the majority of the sample (<20% change). Three preferences showed greater change. More functionally able residents were more likely to change their importance on "being with groups of people," and older residents were more likely to change their preferences for being "involved in religious practices" and "around animals such as pets". Overall, annual assessments of recreational activity preferences capture an accurate representation of preferences with reassessment only needed in a few circumstances.
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Affiliation(s)
| | - Katherine M Abbott
- Department of Sociology and Gerontology, Scripps Gerontology Center, Miami University, Oxford, OH, USA
| | - Michael J Rovine
- Graduate School of Education, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen Eshraghi
- The Pennsylvania State University, College of Nursing, University Park, PA, USA
| | - Caroline Madrigal
- Advanced Fellow in Health Services Research, Center for Innovation in Long-Term Services & Supports, Providence VA, Providence, RI, USA
| | - Victoria Crumbie
- The Pennsylvania State University, College of Nursing, University Park, PA, USA
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27
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McCarthy MS, McCarthy MW. Ethical challenges of prospective clinical trials during the COVID-19 pandemic. Expert Rev Anti Infect Ther 2022; 20:549-554. [PMID: 34797183 PMCID: PMC8631693 DOI: 10.1080/14787210.2022.2009343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/18/2021] [Indexed: 10/29/2022]
Abstract
INTRODUCTION The COVID-19 pandemic has created an unprecedented opportunity to reimagine clinical research. While much has been written about the challenges associated with generating real-world evidence during the COVID-19 pandemic, comparatively little attention has been paid to the ethical challenges facing patients, clinicians, researchers, and regulatory bodies. AREAS COVERED In this manuscript, we examine these challenges through the lens of informed consent and explore how the consenting process changes as our understanding of the disease is altered. EXPERT OPINION We also suggest ways to limit these ethical hurdles through the use of embedded pragmatic clinical trials, which generate real-world data without the limitations associated with observational trials or the resources and lack of generalizability that are obstacles to conducting conventional randomized clinical trials. We argue that clinical research must become more nimble, and must include embedded researchers to ensure that relevant questions and ethical issues are properly addressed.
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Affiliation(s)
| | - Matthew W. McCarthy
- Weill Cornell Medical College, Division of General Internal Medicine, New York-Presbyterian Hospital, New York, NY, USA
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28
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Baker ZG, Gustavson AM, Mitchell LL, Gaugler JE. Open science in dementia care embedded pragmatic clinical trials. Psychol Aging 2022; 37:51-59. [PMID: 35113614 PMCID: PMC8827495 DOI: 10.1037/pag0000644] [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] [Indexed: 02/03/2023]
Abstract
Few dementia care interventions have been translated to healthcare contexts for those who need them. Embedded pragmatic clinical trials (ePCTs) are one design that can expedite the timeframe of research translation to clinical practice. As the National Institutes of Health (NIH) and other funders commit immense new resources to increasing the nation's capacity to conduct dementia care ePCTs, we call on psychologists to employ their extensive expertise in open science to improve the quality of dementia care ePCTs. This article provides several recommendations to enhance the transparency and reporting rigor of ePCTs in dementia care and other chronic disease contexts. We illustrate these recommendations in the context of a recent pilot pragmatic trial known as the Porchlight Project. Porchlight provided training to volunteers who serve clients and caregivers to help them provide more "dementia capable" support. Notably this trial did not include a special effort to make use of open science practices. We discuss the benefits and costs had the Porchlight Project incorporated open science principles. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Zachary G. Baker
- Division of Health Policy and Management, University of Minnesota
| | - Allison M. Gustavson
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System
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29
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Taljaard M, Li F, Qin B, Cui C, Zhang L, Nicholls SG, Carroll K, Mitchell SL. Methodological challenges in pragmatic trials in Alzheimer's disease and related dementias: Opportunities for improvement. Clin Trials 2021; 19:86-96. [PMID: 34841910 DOI: 10.1177/17407745211046672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS We need more pragmatic trials of interventions to improve care and outcomes for people living with Alzheimer's disease and related dementias. However, these trials present unique methodological challenges in their design, analysis, and reporting-often, due to the presence of one or more sources of clustering. Failure to account for clustering in the design and analysis can lead to increased risks of Type I and Type II errors. We conducted a review to describe key methodological characteristics and obtain a "baseline assessment" of methodological quality of pragmatic trials in dementia research, with a view to developing new methods and practical guidance to support investigators and methodologists conducting pragmatic trials in this field. METHODS We used a published search filter in MEDLINE to identify trials more likely to be pragmatic and identified a subset that focused on people living with Alzheimer's disease or other dementias or included them as a defined subgroup. Pairs of reviewers extracted descriptive information and key methodological quality indicators from each trial. RESULTS We identified N = 62 eligible primary trial reports published across 36 different journals. There were 15 (24%) individually randomized, 38 (61%) cluster randomized, and 9 (15%) individually randomized group treatment designs; 54 (87%) trials used repeated measures on the same individual and/or cluster over time and 17 (27%) had a multivariate primary outcome (e.g. due to measuring an outcome on both the patient and their caregiver). Of the 38 cluster randomized trials, 16 (42%) did not report sample size calculations accounting for the intracluster correlation and 13 (34%) did not account for intracluster correlation in the analysis. Of the 9 individually randomized group treatment trials, 6 (67%) did not report sample size calculations accounting for intracluster correlation and 8 (89%) did not account for it in the analysis. Of the 54 trials with repeated measurements, 45 (83%) did not report sample size calculations accounting for repeated measurements and 19 (35%) did not utilize at least some of the repeated measures in the analysis. No trials accounted for the multivariate nature of their primary outcomes in sample size calculation; only one did so in the analysis. CONCLUSION There is a need and opportunity to improve the design, analysis, and reporting of pragmatic trials in dementia research. Investigators should pay attention to the potential presence of one or more sources of clustering. While methods for longitudinal and cluster randomized trials are well developed, accessible resources and new methods for dealing with multiple sources of clustering are required. Involvement of a statistician with expertise in longitudinal and clustered designs is recommended.
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Affiliation(s)
- Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Bo Qin
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Caroline Cui
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Leyi Zhang
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Susan L Mitchell
- Hebrew Senior Life Marcus Institute for Aging Research, Boston, MA, USA
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30
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Bynum JPW, Dorr DA, Lima J, McCarthy EP, McCreedy E, Platt R, Vydiswaran VGV. Using Healthcare Data in Embedded Pragmatic Clinical Trials among People Living with Dementia and Their Caregivers: State of the Art. J Am Geriatr Soc 2021; 68 Suppl 2:S49-S54. [PMID: 32589274 DOI: 10.1111/jgs.16617] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 12/16/2022]
Abstract
Embedded pragmatic clinical trials (ePCTs) are embedded in healthcare systems as well as their data environments. For people living with dementia (PLWD), settings of care can be different from the general population and involve additional people whose information is also important. The ePCT designs have the opportunity to leverage data that becomes available through the normal delivery of care. They may be particularly valuable in Alzheimer's disease and Alzheimer's disease-related dementia (AD/ADRD), given the complexity of case identification and the diversity of care settings. Grounded in the objectives of the Data and Technical Core of the newly established National Institute on Aging Imbedded Pragmatic Alzheimer's Disease and AD-Related Dementias Clinical Trials Collaboratory (IMPACT Collaboratory), this article summarizes the state of the art in using existing data sources (eg, Medicare claims, electronic health records) in AD/ADRD ePCTs and approaches to integrating them in real-world settings. J Am Geriatr Soc 68:S49-S54, 2020.
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Affiliation(s)
- Julie P W Bynum
- Department of Internal Medicine, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - David A Dorr
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Julie Lima
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - V G Vinod Vydiswaran
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA.,School of Information, University of Michigan, Ann Arbor, Michigan, USA
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31
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Hanson LC, Bennett AV, Jonsson M, Kelley A, Ritchie C, Saliba D, Teno J, Zimmerman S. Selecting Outcomes to Ensure Pragmatic Trials Are Relevant to People Living with Dementia. J Am Geriatr Soc 2021; 68 Suppl 2:S55-S61. [PMID: 32589279 DOI: 10.1111/jgs.16619] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/04/2020] [Accepted: 04/10/2020] [Indexed: 11/29/2022]
Abstract
Outcome measures for embedded pragmatic clinical trials (ePCTs) should reflect the lived experience of people living with dementia (PLWD) and their caregivers, yet patient- and caregiver-reported outcomes (PCROs) are rarely available in large clinical and administrative data sources. Although pragmatic methods may lead to use of existing administrative data rather than new data collected directly from PLWD, interventions are truly impactful only when they change outcomes prioritized by PLWD and their caregivers. The Patient- and Caregiver-Reported Outcomes Core (PCRO Core) of the IMbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias Clinical Trials (IMPACT) Collaboratory aims to promote optimal use of outcomes relevant to PLWD and their caregivers in pragmatic trials. The PCRO Core will address key scientific challenges limiting outcome measurement, such as gaps in existing measures, methodologic constraints, and burdensome data capture. PCRO Core investigators will create a searchable library of AD/AD-related dementias (ADRD) clinical outcome measures, including measures in existing data sources with potential for AD/ADRD ePCTs, and will support best practices in measure development, including pragmatic adaptation of PCROs. Working together with other Cores and Teams within the IMPACT Collaboratory, the PCRO Core will support investigators to select from existing outcome measures, and to innovate in methods for measurement and data capture. In the future, the work of the IMPACT Collaboratory may galvanize broader embedded use of outcomes that matter to PLWD and their care partners in large health systems. J Am Geriatr Soc 68:S55-S61, 2020.
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Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Antonia V Bennett
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Patient Reported Outcomes Core, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mattias Jonsson
- Patient Reported Outcomes Core, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amy Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Debra Saliba
- Borun Center, University of California, Los Angeles, Los Angeles, California, USA.,Los Angeles VA Geriatric Research Education and Clinical Center, Los Angeles, California, USA.,RAND, Santa Monica, California, USA
| | - Joan Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health Sciences University, Portland, Oregon, USA
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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32
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Parks RM, Holmes HM, Cheung KL. Current Challenges Faced by Cancer Clinical Trials in Addressing the Problem of Under-Representation of Older Adults: A Narrative Review. Oncol Ther 2021; 9:55-67. [PMID: 33481206 PMCID: PMC7820837 DOI: 10.1007/s40487-021-00140-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/09/2021] [Indexed: 12/11/2022] Open
Abstract
The number of older adults living with cancer is increasing. There is a clear lack of representation of older adults in clinical trials, including cancer trials. Reasons for this are multifactorial and complex and include protocol, patient and sponsor factors. Potential solutions to overcome issues with trial design include varied methods of recruitment with flexible inclusion criteria. Possible alternatives to randomised trials include prospective cohort studies, pragmatic trials and the use of national population-based data sets. Patient factors may be addressed by integration of geriatric assessment, so patients can be randomised or treated based on their individual needs. Additionally, standard protocols for including older adults with cognitive impairment should be developed, rather than automatic exclusion. Increased effort is needed from sponsors and governing health care bodies to make recruitment of older adults to clinical trials standard.
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Affiliation(s)
- Ruth M Parks
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, University of Texas Health Science Center McGovern Medical School, Houston, USA
| | - Kwok-Leung Cheung
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK.
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33
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Rosebush CE, Stabler H, Nkimbeng M, Louwagie K, Fields NL, Jutkowitz E, Shippee TP, Gaugler JE. The Porchlight Project: A Pilot Study to Adapt the Senior Companion Program to Enhance Memory Care Services and Supports. Gerontol Geriatr Med 2021; 7:23337214211017651. [PMID: 34036120 PMCID: PMC8127785 DOI: 10.1177/23337214211017651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/14/2021] [Accepted: 04/20/2021] [Indexed: 11/15/2022] Open
Abstract
Older adult volunteer programs present an important opportunity to provide low cost, community-based support to families living with Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD). In this mixed methods pilot study, volunteers (n = 15) from the Minnesota Senior Companion Program received training in AD/ADRD and palliative care, with the objective of providing more "dementia capable" support to people living with memory loss and their family caregivers. Volunteers applied their skills by engaging clients in a series of guided conversations over 3 months of dementia capable visits. Despite enrollment challenges, volunteers, clients, and caregivers reported that the intervention was appropriate and useful to improve understanding of memory loss and enhance volunteer-client communication. Results of the pilot study were used to refine the Porchlight Project for a future statewide evaluation.
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Affiliation(s)
| | - Henry Stabler
- University of Minnesota School of Public Health, Minneapolis, USA
| | - Manka Nkimbeng
- University of Minnesota School of Public Health, Minneapolis, USA
| | - Katie Louwagie
- University of Minnesota School of Public Health, Minneapolis, USA
| | | | - Eric Jutkowitz
- Brown University School of Public Health, Providence, RI, USA
| | | | - Joseph E Gaugler
- University of Minnesota School of Public Health, Minneapolis, USA
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34
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Campbell NL, Holden RJ, Tang Q, Boustani MA, Teal E, Hillstrom J, Tu W, Clark DO, Callahan CM. Multicomponent behavioral intervention to reduce exposure to anticholinergics in primary care older adults. J Am Geriatr Soc 2021; 69:1490-1499. [PMID: 33772749 DOI: 10.1111/jgs.17121] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To test the impact of a multicomponent behavioral intervention to reduce the use of high-risk anticholinergic medications in primary care older adults. DESIGN Cluster-randomized controlled trial. SETTING AND PARTICIPANTS Ten primary care clinics within Eskenazi Health in Indianapolis. INTERVENTION The multicomponent intervention included provider- and patient-focused components. The provider-focused component was computerized decision support alerting of the presence of a high-risk anticholinergic and offering dose- and indication-specific alternatives. The patient-focused component was a story-based video providing education and modeling an interaction with a healthcare provider resulting in a medication change. Alerts within the medical record triggered staff to play the video for a patient. Our design intended for parallel, independent priming of both providers and patients immediately before an outpatient face-to-face interaction. MEASUREMENT Medication orders were extracted from the electronic medical record system to evaluate the prescribing behavior and population prevalence of anticholinergic users. The intervention was introduced April 1, 2019, through March 31, 2020, and a preintervention observational period of April 1, 2018, through March 31, 2019, facilitated difference in difference comparisons. RESULTS A total of 552 older adults had visits at primary care sites during the study period, with mean age of 72.1 (SD 6.4) years and 45.3% African American. Of the 259 provider-focused alerts, only three (1.2%) led to a medication change. Of the 276 staff alerts, 4.7% were confirmed to activate the patient-focused intervention. The intervention resulted in no significant differences in either the number of discontinue orders for anticholinergics (intervention: two additional orders; control: five fewer orders, p = 0.7334) or proportion of the population using anticholinergics following the intervention (preintervention: 6.2% and postintervention: 5.1%, p = 0.6326). CONCLUSION This multicomponent intervention did not reduce the use of high-risk anticholinergics in older adults receiving primary care. Improving nudges or a policy-focused component may be necessary to reduce use of high-risk medications.
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Affiliation(s)
- Noll L Campbell
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana, USA.,Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richard J Holden
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Qing Tang
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Malaz A Boustani
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Evgenia Teal
- Data Core, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jennifer Hillstrom
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA
| | - Wanzhu Tu
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Daniel O Clark
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christopher M Callahan
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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35
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Harrison J, Mor V, Mitchell S, McCarthy EP. Reflections on the IJHPR's article collection on dementia. Isr J Health Policy Res 2020; 9:50. [PMID: 33023673 PMCID: PMC7537951 DOI: 10.1186/s13584-020-00411-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/30/2020] [Indexed: 11/10/2022] Open
Abstract
Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) constitute a worldwide public health crisis. In light of the AD/ADRD epidemic now existing within the global COVID-19 pandemic, the need for global action to improve dementia care is greater than ever. The article collection "Dementia- an Interdisciplinary Approach," in the Israeli Journal of Health Policy and Research (IJHPR) highlights the need for interprofessional approaches to improving outcomes for people living with dementia and their care partners, as well as the complexities of conducting dementia care research.
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Affiliation(s)
- Jill Harrison
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Box G-S121 (6), Providence, RI, 02912, USA.
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Box G-S121 (6), Providence, RI, 02912, USA
- Providence Veterans Administration Medical Center, Center of Innovation in Health Services Research and Development Service, Providence, RI, USA
| | - Susan Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA, USA
| | - Ellen P McCarthy
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA, USA
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36
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Callahan CM, Unroe KT. How Do We Make Comprehensive Dementia Care a Benefit? J Am Geriatr Soc 2020; 68:2486-2488. [PMID: 32975816 DOI: 10.1111/jgs.16805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/08/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Christopher M Callahan
- Indiana University Center for Aging Research, Indianapolis, Indiana.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana.,Indiana University School of Medicine, Department of Medicine, Indianapolis, Indiana
| | - Kathleen T Unroe
- Indiana University Center for Aging Research, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana.,Indiana University School of Medicine, Department of Medicine, Indianapolis, Indiana
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37
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Gitlin LN, Baier RR, Jutkowitz E, Baker ZG, Gustavson AM, Sefcik JS, Hodgson NA, Koeuth S, Gaugler JE. Dissemination and Implementation of Evidence-Based Dementia Care Using Embedded Pragmatic Trials. J Am Geriatr Soc 2020; 68 Suppl 2:S28-S36. [PMID: 32589277 PMCID: PMC7470172 DOI: 10.1111/jgs.16622] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/07/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022]
Abstract
There are many nonpharmacologic interventions tested in randomized clinical trials that demonstrate significant benefits for people living with Alzheimer's disease (AD) and AD-related dementia, their care partners, or professional care providers. Nevertheless, with few exceptions, proven interventions have not been translated for delivery in real-world settings, such as home care, primary care, hospitals, community-based services, adult day services, assisted living, nursing homes, or other healthcare systems (HCSs). Using embedded pragmatic clinical trial (ePCT) methods is one approach that can facilitate dissemination and implementation (D&I) of dementia care interventions. The science of D&I can inform the integration of evidence-based dementia care in HCSs by offering theoretical frameworks that capture field complexities and guiding evaluation of implementation processes. Also, D&I science can suggest evidence-based strategies for implementing dementia care in HCSs. Although D&I considerations can inform each stage of dementia care intervention development, it is particularly critical when designing ePCTs. This article examines fundamental considerations for implementing dementia-specific interventions in HCSs and how best to prepare for successful dissemination upstream in the context of ePCTs, thereby illustrating the critical role of the D&I Core of the National Institute on Aging Imbedded Pragmatic Alzheimer's Disease and AD-Related Dementias Clinical Trials Collaboratory. The scientific premise of the D&I Core is that having the "end" in mind, upfront in the design and testing of dementia care programs, can lead to decision-making that optimizes the ultimate goal of wide-scale D&I of evidence-based dementia care programs in HCSs. J Am Geriatr Soc 68:S28-S36, 2020.
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Affiliation(s)
- Laura N Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania, USA
| | - Rosa R Baier
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Eric Jutkowitz
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Zachary G Baker
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Allison M Gustavson
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Administration Healthcare System, Minneapolis, Minnesota, USA
| | - Justine S Sefcik
- College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania, USA
| | - Nancy A Hodgson
- Biobehavioral Health Sciences Department, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sokha Koeuth
- College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania, USA
| | - Joseph E Gaugler
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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38
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Brody AA, Barnes DE, Chodosh J, Galvin JE, Hepburn KW, Troxel AB, Hom K, McCarthy EP, Unroe KT. Building a National Program for Pilot Studies of Embedded Pragmatic Clinical Trials in Dementia Care. J Am Geriatr Soc 2020; 68 Suppl 2:S14-S20. [PMID: 32589282 PMCID: PMC7393801 DOI: 10.1111/jgs.16618] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/03/2020] [Accepted: 04/10/2020] [Indexed: 12/24/2022]
Abstract
Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation's ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14-S20, 2020.
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Affiliation(s)
- Abraham A. Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing
| | - Deborah E. Barnes
- Departments of Psychiatry and Epidemiology & Biostatistics, University of California, San Francisco School of Medicine, San Francisco Veterans Affairs Health Care System
| | - Joshua Chodosh
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine
| | - James E. Galvin
- Department of Neurology, University of Miami Miller School of Medicine
| | - Kenneth W. Hepburn
- Nell Hodgson Woodruff School of Nursing, NYU Grossman School of Medicine
| | | | - Kimberly Hom
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing
| | - Ellen P. McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Kathleen T. Unroe
- Indiana University School of Medicine, Center for Aging Research, Regenstrief Institute
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39
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Allore HG, Goldfeld KS, Gutman R, Li F, Monin JK, Taljaard M, Travison TG. Statistical Considerations for Embedded Pragmatic Clinical Trials in People Living with Dementia. J Am Geriatr Soc 2020; 68 Suppl 2:S68-S73. [PMID: 32589276 DOI: 10.1111/jgs.16616] [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: 02/22/2020] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/17/2022]
Abstract
There is overwhelming need for nonpharmacological interventions to improve the health and well-being of people living with dementia (PLWD). The National Institute on Aging Imbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias Clinical Trials (IMPACT) Collaboratory supports clinical trials of such interventions embedded in healthcare systems. The embedded pragmatic clinical trial (ePCT) is ideally suited to testing the effectiveness of complex interventions in vulnerable populations at the point of care. These trials, however, are complex to conduct and interpret, and face challenges in efficiency (i.e., statistical power) and reproducibility. In addition, trials conducted among PLWD present specific statistical challenges, including difficulty in outcomes ascertainment from PLWD, necessitating reliance on reports by caregivers, and heterogeneity in measurements across different settings or populations. These and other challenges undercut the reliability of measurement, the feasibility of capturing outcomes using pragmatic designs, and the ability to validly estimate interventions' effectiveness in real-world settings. To address these challenges, the IMPACT Collaboratory has convened a Design and Statistics Core, the goals of which are: to support the design and conduct of ePCTs directed toward PLWD and their caregivers; to develop guidance for conducting embedded trials in this population; and to educate quantitative and clinical scientists in the design, conduct, and analysis of these trials. In this article, we discuss some of the contemporary methodological challenges in this area and develop a set of research priorities the Design and Statistics Core will undertake to meet these goals. J Am Geriatr Soc 68:S68-S73, 2020.
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Affiliation(s)
- Heather G Allore
- Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut, USA.,Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Keith S Goldfeld
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Fan Li
- Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Joan K Monin
- Department of Social and Behavioral Sciences, School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas G Travison
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
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40
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Tuzzio L, Hanson LR, Reuben DB, Baier RR, Gurwitz JH, Bayliss EA, Williamson J, Fraser JR, Sherman SJ, Larson EB. Transforming Dementia Care Through Pragmatic Clinical Trials Embedded in Learning Healthcare Systems. J Am Geriatr Soc 2020; 68 Suppl 2:S43-S48. [PMID: 32589283 DOI: 10.1111/jgs.16629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 01/18/2023]
Abstract
The current evidence base for testing nonpharmacological interventions for people living with dementia (PLWD) and their caregivers is limited, especially within care settings such as ambulatory care, assisted living communities, nursing homes, hospitals, and hospices. There has been even less attention to translation of effective interventions for PLWD into delivery of care. Thus, there is an urgent need for researchers to partner with these care settings, especially those that follow a learning healthcare systems (LHSs) model, and vice versa to conduct embedded pragmatic clinical trials (ePCTs). These trials are conducted within sites that offer routine care and are designed to answer important, relevant clinical questions and leverage existing electronic health and administrative data. ePCTs set in LHSs create a unique opportunity for researchers, healthcare providers, and PLWD and their families to work and learn together as potentially effective interventions are studied and stress tested in real-world situations. Healthcare settings that embrace research or quality improvement as part of a culture of continuous learning are ideal settings for ePCTs. In this article, we summarize what we have learned from the National Institutes of Health's Health Care Systems Research Collaboratory-funded ePCTs, discuss challenges of ePCTs within settings that serve PLWD, and describe the work of the Health Care Systems Core within the National Institute on Aging's IMbedded Alzheimer's Disease and Related Dementias Clinical Trials Collaboratory that will occur over the next 5 years. J Am Geriatr Soc 68:S43-S48, 2020.
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Affiliation(s)
- Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Leah R Hanson
- HealthPartners Institute, Minneapolis, Minnesota, USA
| | - David B Reuben
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rosa R Baier
- Center for Long-Term Care Quality & Innovation Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA.,Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeff Williamson
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - James R Fraser
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | | | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
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