Addressing methodological challenges in implementing the nursing home pain management algorithm randomized controlled trial

A Citation Review of 83 Dissemination and Implementation Theories, Models, or Frameworks Utilized in U.S.-Based Aging Research

BACKGROUND AND OBJECTIVES

Dissemination-implementation.org outlines 110 theories, models, and frameworks (TMFs): we conducted a citation analysis on 83 TMFs, searching Web of Science and PubMed databases.

RESEARCH DESIGN AND METHODS

Search terms were broad and included "aging," "older," "elderly," and "geriatric." We extracted each TMF in identified articles from inception through January 28, 2022. Included articles must have used a TMF in research or quality improvement work directly linked to older adults within the United States.

RESULTS

We reviewed 2,681 articles of which 295 articles cited at least one of 56 TMFs. Five TMFs represented 50% of the citations: Reach, Effectiveness, Adoption, Implementation, and Maintenance 1.0, Consolidated Framework for Implementation Research, Greenhalgh Diffusion of Innovation in Service Organizations, Quality Enhancement Research Initiative, Community-Based Participatory Research, and Promoting Action on Research Implementation in Health Services. TMF application varied and there was a steady increase in TMF citations over time, with a 2- to 3-fold increase in citations in 2020-2021. We identified that only 41% of TMF use was meaningful.

DISCUSSION AND IMPLICATIONS

Our results suggest TMF utilization is increasing in aging research, but there is a need to more meaningful utilize TMFs. As the population of older adults continues to grow, there will be increasing demand for effective evidence-based practices and models of care to be quickly and effectively translated into routine care. Use of TMFs is critical to building such evidence and to identifying and evaluating methods to support this translation.

Algorithm-based pain management for people with dementia in nursing homes

BACKGROUND

People with dementia in nursing homes often experience pain, but often do not receive adequate pain therapy. The experience of pain has a significant impact on quality of life in people with dementia, and is associated with negative health outcomes. Untreated pain is also considered to be one of the causes of challenging behaviour, such as agitation or aggression, in this population. One approach to reducing pain in people with dementia in nursing homes is an algorithm-based pain management strategy, i.e. the use of a structured protocol that involves pain assessment and a series of predefined treatment steps consisting of various non-pharmacological and pharmacological pain management interventions.

OBJECTIVES

To assess the effects of algorithm-based pain management interventions to reduce pain and challenging behaviour in people with dementia living in nursing homes. To describe the components of the interventions and the content of the algorithms.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science Core Collection (ISI Web of Science), LILACS (Latin American and Caribbean Health Science Information database), ClinicalTrials.gov and the World Health Organization's meta-register the International Clinical Trials Registry Portal on 30 June 2021.

SELECTION CRITERIA

We included randomised controlled trials investigating the effects of algorithm-based pain management interventions for people with dementia living in nursing homes. All interventions had to include an initial pain assessment, a treatment algorithm (a treatment plan consisting of at least two different non-pharmacological or pharmacological treatment steps to reduce pain), and criteria to assess the success of each treatment step. The control groups could receive usual care or an active control intervention. Primary outcomes for this review were pain-related outcomes, e.g. the number of participants with pain (self- or proxy-rated), challenging behaviour (we used a broad definition that could also include agitation or behavioural and psychological symptoms assessed with any validated instrument), and serious adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the articles for inclusion, extracted data and assessed the risk of bias of all included studies. We reported results narratively as there were too few studies for a meta-analysis. We used GRADE methods to rate the certainty of the results.

MAIN RESULTS

We included three cluster-randomised controlled trials with a total of 808 participants (mean age 82 to 89 years). In two studies, participants had severe cognitive impairment and in one study mild to moderate impairment. The algorithms used in the studies varied in the number of treatment steps. The comparator was pain education for nursing staff in two studies and usual care in one study. We judged the risk of detection bias to be high in one study. The risk of selection bias and performance bias was unclear in all studies. Self-rated pain (i.e. pain rated by participants themselves) was reported in two studies. In one study, all residents in the nursing homes were included, but fewer than half of the participants experienced pain at baseline, and the mean values of self-rated and proxy-rated pain at baseline and follow-up in both study groups were below the threshold of pain that may require treatment. We considered the evidence from this study to be very low-certainty and therefore are uncertain whether the algorithm-based pain management intervention had an effect on self-rated pain intensity compared with pain education (MD -0.27, 95% CI -0.49 to -0.05, 170 participants; Verbal Descriptor Scale, range 0 to 3). In the other study, all participants had mild to moderate pain at baseline. Here, we found low-certainty evidence that an algorithm-based pain management intervention may have little to no effect on self-rated pain intensity compared with pain education (MD 0.4, 95% CI -0.58 to 1.38, 246 participants; Iowa Pain Thermometer, range 0 to 12). Pain was rated by proxy in all three studies. Again, we considered the evidence from the study in which mean pain scores indicated no pain, or almost no pain, at baseline to be very low-certainty and were uncertain whether the algorithm-based pain management intervention had an effect on proxy-rated pain intensity compared with pain education. For participants with mild to moderate pain at baseline, we found low-certainty evidence that an algorithm-based pain management intervention may reduce proxy-rated pain intensity in comparison with usual care (MD -1.49, 95% CI -2.11 to -0.87, 1 study, 128 participants; Pain Assessment in Advanced Dementia Scale-Chinese version, range 0 to 10), but may not be more effective than pain education (MD -0.2, 95% CI -0.79 to 0.39, 1 study, 383 participants; Iowa Pain Thermometer, range 0 to 12). For challenging behaviour, we found very low-certainty evidence from one study in which mean pain scores indicated no pain, or almost no pain, at baseline. We were uncertain whether the algorithm-based pain management intervention had any more effect than education for nursing staff on challenging behaviour of participants (MD -0.21, 95% CI -1.88 to 1.46, 1 study, 170 participants; Cohen-Mansfield Agitation Inventory-Chinese version, range 7 to 203). None of the studies systematically assessed adverse effects or serious adverse effects and no study reported information about the occurrence of any adverse effect. None of the studies assessed any of the other outcomes of this review.

AUTHORS' CONCLUSIONS

There is no clear evidence for a benefit of an algorithm-based pain management intervention in comparison with pain education for reducing pain intensity or challenging behaviour in people with dementia in nursing homes. We found that the intervention may reduce proxy-rated pain compared with usual care. However, the certainty of evidence is low because of the small number of studies, small sample sizes, methodological limitations, and the clinical heterogeneity of the study populations (e.g. pain level and cognitive status). The results should be interpreted with caution. Future studies should also focus on the implementation of algorithms and their impact in clinical practice.

Continuing education interventions about person-centered care targeted for nurses in older people long-term care: a systematic review

BACKGROUND

Person-Centered Care is often seen as an indicator of quality of care. However, it is not known whether and to what extent person-centered care can be enhanced by continuing education interventions in older people's long-term care settings. This systematic review aimed to analyze and synthesize the existing research literature about person-centered care-based continuing educational interventions for nurses working in long-term care settings for older people.

METHODS

Five databases were searched 6/2019 and updated 7/2020; PubMed (Medline), CINAHL, PsycINFO, Cochrane and Eric using the keywords person-centered car* OR person-centred car * OR patient-centered car* OR client-centered car* OR tailored car* OR resident-centered car* OR individualized car* AND older* OR elder* OR old person* AND Long-Term Care OR Nursing home OR 24-h treatment OR long-term treatment. Twenty-seven full texts from 2587 initially retrieved citations were included.

RESULTS

The continuing educational interventions found were divided into five themes: person-centered interventions focusing on medication; interaction and caring culture; nurses' job satisfaction; nursing activities; and older people's quality of life. The perspective of older people and their next of kin about the influence of continuing education interventions were largely absent. The background theories about interventions, the measurements taken, and the clarity around the building blocks of the continuing-care interventions need further empirical verification. The pedagogical methods used were mainly quite behavioristic mostly lectures and seminars.

CONCLUSION

Most of person-centered care continuing education interventions are effective. Still more empirical research-based continuing education interventions are needed that include learner-centered pedagogical methods, with measurable outcomes that consider the opinions of older people and their next of kin. Continuing educational interventions for nurses need to be further developed to strengthen nurse's competence in person-centered care, job satisfaction and for better quality of care.

Is it possible to influence ability, willingness and understanding among nursing home care staff to implement nutritional guidelines? A comparison of a facilitated and an educational strategy

BACKGROUND

Translating nutrition knowledge into care practice is challenging since multiple factors can affect the implementation process. This study examined the impact of two implementation strategies, that is external facilitation (EF) and educational outreach visits (EOVs), on the organisational context and individual factors when implementing nutritional guidelines in a nursing home (NH) setting.

METHODS

The EF strategy was a one-year, multifaceted (including support, guidance, a practice audit and feedback) intervention given to four NH units. The EOV strategy was a three-hour lecture about the nutritional guidelines given to four other NH units. Both strategies were directed at selected NH teams, consisting of a unit manager, a nurse and 5-10 care staff. A questionnaire was distributed, before and after the interventions, to evaluate the prerequisites for the staff to use the guidelines. Three conditions were used to examine the organisational context and the individual factors: the staff's ability and willingness to implement the nutritional guidelines and their understanding of them. Confirmatory factor analysis and structural equation models were used for the data analysis.

RESULTS

The results indicated that on average, there was a significant increase in the staff's ability to implement the nutritional guidelines in the EF group. The staff exposed to the EF strategy experienced better resources to implement the guidelines in terms of time, tools and support from leadership and a clearer assignment of responsibility regarding nutrition procedures. There was no change in staff's willingness and understanding of the guidelines in the EF group. On average, no significant changes were observed for the staff's ability, willingness or understanding in the EOV group.

CONCLUSIONS

A long-term, active and flexible implementation strategy (i.e. EF) affected the care staff's ability to implement the nutritional guidelines in an NH setting. No such impact was observed for the more passive, educational approach (i.e. EOV).

A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial)

BACKGROUND

provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence and skills of staff who provide care. This trial assessed the feasibility of undertaking a definitive evaluation of a posture and mobility training programme for care staff.

DESIGN AND SETTING

a cluster randomised controlled feasibility trial with embedded process evaluation. Ten care homes in Yorkshire, United Kingdom, were randomised (1:1) to the skilful care training package (SCTP) or usual care (UC).

PARTICIPANTS

residents who were not independently mobile.

INTERVENTION

SCTP-delivered by physiotherapists to care staff.

OBJECTIVES AND MEASUREMENTS

key objectives informed progression to a definitive trial. Recruitment, retention and intervention uptake were monitored. Data, collected by a blinded researcher, included pain, posture, mobility, hospitalisations and falls. This informed data collection feasibility and participant safety.

RESULTS

a total of 348 residents were screened; 146 were registered (71 UC, 75 SCTP). Forty two were lost by 6 months, largely due to deaths. While data collection from proxy informants was good (>95% expected data), attrition meant that data completion rates did not meet target. Data collection from residents was poor due to high levels of dementia. Intervention uptake was variable-staff attendance at all sessions ranged from 12.5 to 65.8%. There were no safety concerns.

CONCLUSION

care home and resident recruitment are feasible, but refinement of data collection approaches and intervention delivery are needed for this trial and care home research more widely.

Methodological challenges in conducting instrumentation research in non-communicative palliative care patients

Well-designed, rigorously implemented instrumentation studies are essential to develop valid, reliable pain assessment tools in non-communicative (non-self-reporting) palliative care patients. When conducting a pain instrumentation study, a research team identified methodologic challenges surrounding informed consent, eligibility criteria, acute pain operational definitions, patient recruitment, missing data, and study-related training during a run-in phase at the beginning of the project and during the conduct of the study. The team dealt with these challenges through identifying root causes, implementing remedial measures, and collecting data to demonstrate improvement or resolution. Effective strategies included obtaining Institutional Review Board (IRB) approval for a waiver of informed consent, modifying eligibility criteria, ensuring that operational definitions and study procedures were consistent with clinical practice, decreasing time from screening to data collection to improve recruitment, increasing study nurse staffing by re-budgeting grant funds, focusing time and resources on high accruing clinical units, revising processes to minimize missing data, and developing detailed training for users of the instrument. With these multi-pronged solutions, the team exceeded the patient accrual target by 25% within the funding period and reduced missing data. While pain instrumentation studies in non-communicative patients have similar challenges to other palliative care studies, some of the solutions may be unique and several are applicable to other palliative care studies, particularly instrumentation research. The team's experience may also be useful for funders and IRBs.

Pain Management in Nursing Home Residents: Findings from a Pilot Effectiveness-Implementation Study

OBJECTIVES

To evaluate the effectiveness and implementation of a multilevel pain management intervention in nursing homes (NHs) comprising a pain management guideline, care worker training, and pain champions.

DESIGN

An implementation science pilot study using a quasi-experimental effectiveness-implementation (hybrid II) design.

SETTING

Four NHs in Switzerland.

PARTICIPANTS

All consenting long-term residents aged 65 years and older with pain at baseline (N = 62) and all registered and licensed practical nurses (N = 61).

INTERVENTION

Implementation of a contextually adapted pain management guideline, interactive training workshops for all care workers, and specifically trained pain champions.

MEASUREMENTS

Interference from pain, worst and average pain intensity over the previous 24 hours; proxy ratings of pain with the Pain Assessment in Advanced Dementia scale; and care workers' appraisal of the guideline's reach, acceptability, and adoption.

RESULTS

Pain-related outcomes improved for self-reporting residents (n = 43) and residents with proxy rating (n = 19). Significant improvements of average pain from baseline to T1 (P = .006), and in worst pain from baseline to T1 (P = .003) and T2 (P = .004). No significant changes in interference from pain (P = .18). With regard to the implementation efforts, about 76% of care workers indicated they were familiar with the guideline; 70.4% agreed that the guideline is practical and matches their ideas of good pain assessment (75.9%) and treatment (79.7%).

CONCLUSION

Implementation of a multilevel pain management intervention did significantly improve average and worst pain intensity in NH residents. However, to effect clinical meaningful changes in interference from pain, a more comprehensive approach involving other disciplines may be necessary. J Am Geriatr Soc 67:2574-2580, 2019.

Challenges of conducting research in long-term care facilities: a systematic review

Background

The aim of this review is to describe the challenges and barriers to conducting research in long-term care facilities.

Methods

A literature search was conducted in Ovid MEDLINE, Embase, Cochrane Central, PsycINFO and CINAHL. Keywords used included “long term care”, “nursing home”, “research”, “trial”, “challenge” and “barrier”, etc. Resulting references were screened in order to identify relevant studies that reported on challenges derived from first-hand experience of empirical research studies. Challenges were summarized and synthesized.

Results

Of 1723 references, 39 articles were selected for inclusion. To facilitate understanding we proposed a classification framework of 8 main themes to categorize the research challenges presented in the 39 studies, relating to the characteristics of facility/owner/administrator, resident, staff caregiver, family caregiver, investigator, ethical or legal concerns, methodology, and budgetary considerations.

Conclusions

Conducting research in long-term care facilities is full of challenges which can be categorized into 8 main themes. Investigators should be aware of all these challenges and specifically address them when planning their studies. Stakeholders should be involved from an early stage and flexibility should be built into both the methodology and research budget.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0934-9) contains supplementary material, which is available to authorized users.

Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial

OBJECTIVE

To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies.

DESIGN

A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only.

SETTING

Twenty-seven NHs in the greater Puget Sound area participated. Facilities were diverse in terms of size, quality, and ownership.

PARTICIPANTS

Data were collected from 485 NH residents; 259 for the intervention and 226 for the control group.

MEASUREMENTS

Resident outcomes were nursing assistant (proxy) report and self-reported resident pain intensity. Process outcomes were adherence to recommended pain practices. Outcomes were measured at baseline, completion of the intervention (ALG) or training (EDU), and again 6 months later.

RESULTS

Among 8 comparisons of outcome measures between ALG and EDU (changes in 4 primary pain measures compared at 2 postintervention time points) there was only 1 statistically significant but small treatment difference in proxy- or self-reported pain intensity. Resident-reported worst pain decreased by an average of 0.8 points from baseline to 6 months among the EDU group and increased by 0.2 points among the ALG (P = .005), a clinically nonsignificant difference. There were no statistically significant differences in adherence to clinical guideline practice recommendations between ALG and EDU following the intervention.

CONCLUSIONS

Future research needs to identify and test effective implementation methods for changing complex clinical practices in NHs, including those to reduce pain.

A cluster randomized controlled trial comparing relative effectiveness of two licensed influenza vaccines in US nursing homes: Design and rationale

BACKGROUND

Influenza, the most important viral infection affecting older adults, produces a substantial burden in health care costs, morbidity, and mortality. Influenza vaccination remains the mainstay in prevention and is associated with reduced rates of hospitalization, stroke, heart attack, and death in non-institutional older adult populations. Influenza vaccination produces considerably lower antibody response in the elderly compared to young adults. Four-fold higher vaccine antigen (high-dose) than in the standard adult vaccine (standard-dose) elicits higher serum antibody levels and antibody response in ambulatory elderly.

PURPOSE

To describe the design considerations of a large clinical trial of high-dose compared to standard-dose influenza vaccine in nursing homes and baseline characteristics of participating nursing homes and long-stay (more than 90 days) residents over 65 years of age.

METHODS

The high-dose influenza vaccine intervention trial is multifacility, cluster randomized controlled trial with a 2×2 factorial design that compares hospitalization rates, mortality, and functional decline among long-stay nursing home residents in facilities randomized to receive high-dose versus standard-dose influenza vaccine and also randomized with or without free staff vaccines provided by study organizers. Enrollment focused on nursing homes with a large long-stay resident population over 65 years of age. The primary outcome is the resident-level incidence of hospitalization with a primary diagnosis of pulmonary and influenza-like illness, based upon Medicare inpatient hospitalization claims. Secondary outcomes are all-cause mortality based upon the vital status indicator in the Medicare Vital Status file, all-cause hospitalization directly from the nursing home Minimum Data Set discharge records, and the probability of declining at least 4 points on the 28-point Activities of Daily Living Scale.

RESULTS

Between February and September 2013, the high-dose influenza vaccine trial recruited and randomized 823 nursing homes. The analysis sample includes 53,035 long-stay nursing home residents over 65 years of age, representing 57.7% of the participating facilities' population. Residents are mainly women (72.2%), white (75.5%), with a mean age of 83 years. Common conditions include hypertension (79.2%), depression (55.1%), and diabetes mellitus (34.4%). The prevalence of circulatory and pulmonary disorders includes heart failure (20.5%), stroke (20.1%), and asthma/chronic obstructive pulmonary disease (20.2%).

CONCLUSIONS

This high-dose influenza vaccine trial uniquely offers a paradigm for future studies of clinical and programmatic interventions within the framework of efforts designed to test the impact of changes in usual treatment practices adopted by health care systems.

TRIAL REGISTRATION

NCT01815268.

The Method of Randomization for Cluster-Randomized Trials: Challenges of Including Patients with Multiple Chronic Conditions

Cluster-randomized clinical trials (CRT) are trials in which the unit of randomization is not a participant but a group (e.g. healthcare systems or community centers). They are suitable when the intervention applies naturally to the cluster (e.g. healthcare policy); when lack of independence among participants may occur (e.g. nursing home hygiene); or when it is most ethical to apply an intervention to all within a group (e.g. school-level immunization). Because participants in the same cluster receive the same intervention, CRT may approximate clinical practice, and may produce generalizable findings. However, when not properly designed or interpreted, CRT may induce biased results. CRT designs have features that add complexity to statistical estimation and inference. Chief among these is the cluster-level correlation in response measurements induced by the randomization. A critical consideration is the experimental unit of inference; often it is desirable to consider intervention effects at the level of the individual rather than the cluster. Finally, given that the number of clusters available may be limited, simple forms of randomization may not achieve balance between intervention and control arms at either the cluster- or participant-level. In non-clustered clinical trials, balance of key factors may be easier to achieve because the sample can be homogenous by exclusion of participants with multiple chronic conditions (MCC). CRTs, which are often pragmatic, may eschew such restrictions. Failure to account for imbalance may induce bias and reducing validity. This article focuses on the complexities of randomization in the design of CRTs, such as the inclusion of patients with MCC, and imbalances in covariate factors across clusters.

The impact of covariate misclassification using generalized linear regression under covariate-adaptive randomization

Under covariate adaptive randomization, the covariate is tied to both randomization and analysis. Misclassification of such covariate will impact the intended treatment assignment; further, it is unclear what the appropriate analysis strategy should be. We explore the impact of such misclassification on the trial's statistical operating characteristics. Simulation scenarios were created based on the misclassification rate and the covariate effect on the outcome. Models including unadjusted, adjusted for the misclassified, or adjusted for the corrected covariate were compared using logistic regression for a binary outcome and Poisson regression for a count outcome. For the binary outcome using logistic regression, type I error can be maintained in the adjusted model, but the test is conservative using an unadjusted model. Power decreased with both increasing covariate effect on the outcome as well as the misclassification rate. Treatment effect estimates were biased towards the null for both the misclassified and unadjusted models. For the count outcome using a Poisson model, covariate misclassification led to inflated type I error probabilities and reduced power in the misclassified and the unadjusted model. The impact of covariate misclassification under covariate-adaptive randomization differs depending on the underlying distribution of the outcome.

COSMOS--improving the quality of life in nursing home patients: protocol for an effectiveness-implementation cluster randomized clinical hybrid trial

BACKGROUND

Nursing home patients have complex mental and physical health problems, disabilities and social needs, combined with widespread prescription of psychotropic drugs. Preservation of their quality of life is an important goal. This can only be achieved within nursing homes that offer competent clinical conditions of treatment and care. COmmunication, Systematic assessment and treatment of pain, Medication review, Occupational therapy, Safety (COSMOS) is an effectiveness-implementation hybrid trial that combines and implements organization of activities evidence-based interventions to improve staff competence and thereby the patients' quality of life, mental health and safety. The aim of this paper is to describe the development, content and implementation process of the COSMOS trial.

METHODS/DESIGN

COSMOS includes a 2-month pilot study with 128 participants distributed among nine Norwegian nursing homes, and a 4-month multicenter, cluster randomized effectiveness-implementation clinical hybrid trial with follow-up at month 9, including 571 patients from 67 nursing home units (one unit defined as one cluster). Clusters are randomized to COSMOS intervention or current best practice (control group). The intervention group will receive a 2-day education program including written guidelines, repeated theoretical and practical training (credited education of caregivers, physicians and nursing home managers), case discussions and role play. The 1-day midway evaluation, information and interviews of nursing staff and a telephone hotline all support the implementation process. Outcome measures include quality of life in late-stage dementia, neuropsychiatric symptoms, activities of daily living, pain, depression, sleep, medication, cost-utility analysis, hospital admission and mortality.

DISCUSSION

Despite complex medical and psychosocial challenges, nursing home patients are often treated by staff possessing low level skills, lacking education and in facilities with a high staff turnover. Implementation of a research-based multicomponent intervention may improve staff's knowledge and competence and consequently the quality of life of nursing home patients in general and people with dementia in particular.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02238652.

Successful knowledge translation intervention in long-term care: final results from the vitamin D and osteoporosis study (ViDOS) pilot cluster randomized controlled trial

Background

Few studies have systematically examined whether knowledge translation (KT) strategies can be successfully implemented within the long-term care (LTC) setting. In this study, we examined the effectiveness of a multifaceted, interdisciplinary KT intervention for improving the prescribing of vitamin D, calcium and osteoporosis medications over 12-months.

Methods

We conducted a pilot, cluster randomized controlled trial in 40 LTC homes (21 control; 19 intervention) in Ontario, Canada. LTC homes were eligible if they had more than one prescribing physician and received services from a large pharmacy provider. Participants were interdisciplinary care teams (physicians, nurses, consultant pharmacists, and other staff) who met quarterly. Intervention homes participated in three educational meetings over 12 months, including a standardized presentation led by expert opinion leaders, action planning for quality improvement, and audit and feedback review. Control homes did not receive any additional intervention. Resident-level prescribing and clinical outcomes were collected from the pharmacy database; data collectors and analysts were blinded. In addition to feasibility measures, study outcomes were the proportion of residents taking vitamin D (≥800 IU/daily; primary), calcium ≥500 mg/day and osteoporosis medications (high-risk residents) over 12 months. Data were analyzed using the generalized estimating equations technique accounting for clustering within the LTC homes.

Results

At baseline, 5,478 residents, mean age 84.4 (standard deviation (SD) 10.9), 71% female, resided in 40 LTC homes, mean size = 137 beds (SD 76.7). In the intention-to-treat analysis (21 control; 19 intervention clusters), the intervention resulted in a significantly greater increase in prescribing from baseline to 12 months between intervention versus control arms for vitamin D (odds ratio (OR) 1.82, 95% confidence interval (CI): 1.12, 2.96) and calcium (OR 1.33, 95% CI: 1.01, 1.74), but not for osteoporosis medications (OR 1.17, 95% CI: 0.91, 1.51). In secondary analyses, excluding seven nonparticipating intervention homes, ORs were 3.06 (95% CI: 2.18, 4.29), 1.57 (95% CI: 1.12, 2.21), 1.20 (95% CI: 0.90, 1.60) for vitamin D, calcium and osteoporosis medications, respectively.

Conclusions

Our KT intervention significantly improved the prescribing of vitamin D and calcium and is a model that could potentially be applied to other areas requiring quality improvement.

Trial Registration

ClinicalTrials.gov: NCT01398527. Registered: 19 July 2011.

A mixed-methods approach to investigating the adoption of evidence-based pain practices in nursing homes

This mixed methods study examined perceived facilitators and obstacles to adopting evidence-based pain management protocols vis-a-vis documented practice changes that were measured using a chart audit tool. This analysis used data from a subgroup of four nursing homes that participated in a clinical trial. Focus group interviews with staff yielded qualitative data about perceived factors that affected their willingness and ability to use the protocols. Chart audits determined whether pain assessment and management practices changed over time in light of these reported facilitators and barriers. Reported facilitators included administrative support, staff consistency, and policy and procedure changes. Barriers were staff attitudes, regulatory issues, and provider mistrust of nurses' judgment. Overall, staff reported improvements in pain practices. These reports were corroborated by modest but significant increases in adherence to recommended practices. Change in clinical practice is complex and requires attention to both structural and process aspects of care.

Geriatric palliative care in long-term care settings with a focus on nursing homes

Almost 1.7 million older Americans live in nursing homes, representing a large proportion of the frailest, most vulnerable elders needing long-term care. In the future, increasing numbers of older adults are expected to spend time and to die in nursing homes. Thus, understanding and addressing the palliative care needs of this population are critical. The goals of this paper are to describe briefly the current state of knowledge about palliative care needs, processes, and outcomes for nursing home residents; identify gaps in this knowledge; and propose priorities for future research in this area.