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Chambers D, Cantrell A, Preston L, Marincowitz C, Wright L, Conroy S, Lee Gordon A. Reducing unplanned hospital admissions from care homes: a systematic review. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-130. [PMID: 37916580 DOI: 10.3310/klpw6338] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Background Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost. Objectives Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings. Data sources We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. 'Grey' literature (January 2022) and citations were searched and reference lists were checked. Methods We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect. Results We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence. Conclusions Effective implementation of interventions at various stages of residents' care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation. Limitations Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible. Future work We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes. Study registration This study is registered as PROSPERO database CRD42021289418. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Louise Preston
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Carl Marincowitz
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Adam Lee Gordon
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham, UK
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Poupin P, Caille A, Gana W, Fougère B, Giraudeau B. Cluster randomized trials in nursing homes should better be planned as open-cohort than as closed-cohort. J Clin Epidemiol 2023; 161:1-7. [PMID: 37364621 DOI: 10.1016/j.jclinepi.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/31/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Two designs are frequently used in cluster randomized trials in nursing homes: closed cohort and open cohort. The former design includes residents at the beginning of the trial and then follows them. In the latter design, participants are enrolled at the beginning of the trial or although it is ongoing; at dates of assessment, all residents present in the nursing home are assessed. The open-cohort design is much less used than the closed-cohort design, but it offers several advantages such as less exposure to individual attrition. Objective was to assess whether an open-cohort design could have been feasible in trials with a closed-cohort design. STUDY DESIGN AND SETTING Twenty-two closed-cohort trials in nursing homes. RESULTS An open-cohort design was considered a relevant alternative for 20 trials. For 16 trials, a resident newly admitted could not opt out of the intervention, and for all trials, the resident could benefit from an intervention effect if it existed. For two trials, newly admitted residents could not benefit from the intervention effect, if it existed. CONCLUSION The open-cohort design is well-adapted for most of the interventions assessed in nursing homes by means of a cluster randomized trial and should be considered more often.
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Affiliation(s)
- Pierre Poupin
- INSERM, SPHERE, U1246, Tours University, Nantes University, Tours, France; INSERM CIC 1415, Tours University Hospital, Tours, France.
| | - Agnès Caille
- INSERM, SPHERE, U1246, Tours University, Nantes University, Tours, France; INSERM CIC 1415, Tours University Hospital, Tours, France
| | - Wassim Gana
- Division of Geriatric Medicine, Tours University Medical Center, Tours, France
| | - Bertrand Fougère
- Division of Geriatric Medicine, Tours University Medical Center, Tours, France; Education, Ethics, Health (EA 7505), Tours University, Tours, France
| | - Bruno Giraudeau
- INSERM, SPHERE, U1246, Tours University, Nantes University, Tours, France; INSERM CIC 1415, Tours University Hospital, Tours, France
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Kelly S, Cowan A, Akdur G, Irvine L, Peryer G, Welsh S, Rand S, Lang IA, Towers AM, Spilsbury K, Killett A, Gordon AL, Hanratty B, Jones L, Meyer J, Goodman C, Burton JK. Outcome measures from international older adult care home intervention research: a scoping review. Age Ageing 2023; 52:afad069. [PMID: 37192505 PMCID: PMC10187991 DOI: 10.1093/ageing/afad069] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Care homes are increasingly important settings for intervention research to enhance evidence-informed care. For such research to demonstrate effectiveness, it is essential that measures are appropriate for the population, setting and practice contexts. OBJECTIVE To identify care home intervention studies and describe the resident outcome measures used. DESIGN Scoping review. METHODS We reviewed international care home research published from 2015 to August 2022. We searched MEDLINE, EMBASE, CINAHL and ASSIA. We included any intervention study conducted in a care home, reporting resident outcomes. We extracted resident outcome measures, organised these using the domains of an adapted framework and described their use. RESULTS From 7,330 records screened, we included 396 datasets reported in 436 publications. These included 12,167 care homes and 836,842 residents, with an average of 80 residents per study. The studies evaluated 859 unique resident outcomes 2,030 times using 732 outcome measures. Outcomes were evaluated between 1 and 112 times, with 75.1% of outcomes evaluated only once. Outcome measures were used 1-120 times, with 68.4% of measures used only once. Only 14 measures were used ≥20 times. Functional status, mood & behaviour and medications were the commonest outcome domains assessed. More than half of outcomes were assessed using scales, with a fifth using existing records or administrative data. CONCLUSIONS There is significant heterogeneity in the choice and assessment of outcomes for intervention research in care homes. There is an urgent need to develop a consensus on useful and sensitive tools for care homes, working with residents, families and friends and staff.
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Affiliation(s)
- Sarah Kelly
- Cambridge Public Health, University of Cambridge, East Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
- THIS Institute, University of Cambridge, Clifford Allbutt Building, Cambridge Biomedical Campus, Cambridge CB2 0AH, UK
| | - Andy Cowan
- Cambridge Public Health, University of Cambridge, East Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - Gizdem Akdur
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield AL10 9AB, UK
| | - Lisa Irvine
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield AL10 9AB, UK
| | - Guy Peryer
- School of Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
- NIHR Applied Research Collaboration, East of England, CB2 8AH, UK
| | - Silje Welsh
- School of Cardiovascular and Metabolic Health, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Alexandra Parade, Glasgow G31 2ER, UK
| | - Stacey Rand
- Personal Social Services Research Unit, University of Kent, Cornwallis Central, Canterbury CT2 7NF, UK
| | - Iain A Lang
- Department of Health and Community Sciences, University of Exeter, St Luke’s Campus, Exeter EX1 2LU, UK
- NIHR Applied Research Collaboration, South West Peninsula, EX1 2LU, UK
| | - Ann-Marie Towers
- Centre for Health Services Studies, Cornwallis Central, University of Kent, Canterbury CT2 7NF, UK
- NIHR Applied Research Collaboration, Kent Surrey and Sussex, BN3 7HZ, UK
| | - Karen Spilsbury
- School of Healthcare, University of Leeds, Baines Wing, Leeds LS2 9JT, UK
- NIHR Applied Research Collaboration, Yorkshire and Humber, BD9 6RJ, UK
| | - Anne Killett
- School of Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
- NIHR Applied Research Collaboration, East of England, CB2 8AH, UK
| | - Adam Lee Gordon
- Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3DT, UK
- NIHR Applied Research Collaboration, East Midlands, LE5 4PW, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Newcastle-upon-Tyne NE4 5PL, UK
- NIHR Applied Research Collaboration, North East and North Cumbria, NE3 3XT, UK
| | - Liz Jones
- National Care Forum, Friars House, Manor House Drive, Coventry CV1 2TE, UK
| | - Julienne Meyer
- National Care Forum, Friars House, Manor House Drive, Coventry CV1 2TE, UK
- City, University of London, Northampton Square, London EC1V 0HB, UK
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield AL10 9AB, UK
- NIHR Applied Research Collaboration, East of England, CB2 8AH, UK
| | - Jennifer Kirsty Burton
- School of Cardiovascular and Metabolic Health, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Alexandra Parade, Glasgow G31 2ER, UK
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Choong EKM, Gallagher JE, Patel R. Methodology and outcome of trials involving older adults in UK care homes: A rapid review. Gerodontology 2023; 40:1-9. [PMID: 35246883 DOI: 10.1111/ger.12622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 12/14/2021] [Accepted: 01/16/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The United Kingdom (UK) has a well-developed health and social care system, and strong research governance. However, there is limited evidence to guide best research practice among vulnerable older people in care homes and there is no consensus on clinical trial methodology that is deliverable in this setting. OBJECTIVES To review the literature on trials conducted among older adults residing in care homes within the UK and collate evidence on their methodological characteristics and outcomes. METHODS A systematic rapid review methodology was employed. MEDLINE, EMBASE and CENTRAL were searched in two incremental stages: stage 1 searched for oral health-related trials conducted within the UK care homes up to July 2021, whereas stage 2 sought for general health-related trials in the same setting from 2011 to 2021. The quality of included studies was assessed using Cochrane's RoB 2 and ROBINS-I tools. Findings were summarised descriptively. RESULTS Five oral health and 33 general health-related trials involving care home residents were included for analysis. The most common trial design was parallel group with two arms (n = 25) involving individual randomisation (n = 21). Consent was mainly obtained from residents and/or their proxies (n = 24), followed by residents only (n = 13) and care homes only (n = 1). Based on available data, the number needed to screen to recruit one participant ranged from 2 to 40 (median: 3; Q1-Q3: 2-9). Attrition rates ranged from 0% to 73% (median: 21%; Q1-Q3: 13%-32%) for follow-up periods between 1 and 52 weeks. The studies were of mixed methodological quality. CONCLUSION This rapid review outlines the methodological characteristics and outcomes of trials conducted among older adults in UK care homes. The findings of this review provide valuable information to assist in navigating and designing future research in this complex setting.
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Affiliation(s)
- Elaine Kar Man Choong
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK.,Department of Community Oral Health & Clinical Prevention, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
| | - Jennifer E Gallagher
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
| | - Rakhee Patel
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK.,NHSEI (London Region), London, UK
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Gordon AL, Bennett C, Goodman C, Achterberg WP. Making progress: but a way to go-the age and ageing care-home collection. Age Ageing 2022; 51:6399884. [PMID: 34661617 DOI: 10.1093/ageing/afab213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Indexed: 11/14/2022] Open
Abstract
Care homes enable people with advanced physical and cognitive impairment to live well with 24-h support from staff. They are a feature of care systems in most countries. They have proved pivotal to the coronavirus disease 2019 (COVID-19) response. We searched Age and Ageing for care-home articles published since 2015. From these we collated 42 into the Age and Ageing care-home collection. This collection draws together important papers that show how Age and Ageing is helping to shape and grow care-home research. The collection outlines the technical issues that researchers face by grouping together important feasibility trials conducted in the sector. It looks at the challenges of measuring quality of life and working with routine data in care homes. It brings together observational studies considering loneliness, functional dependency, stroke outcomes, prescribing and acute deterioration. Health services research in care homes is represented by two studies that demonstrate realist evaluation as a way to make sense of service innovations. Papers are included that consider: non-pharmacological strategies for residents with dementia, end-of-life care, sexuality and intimacy and the care-home workforce. Given the importance of the COVID-19 pandemic in care homes, all of the care home COVID-19 papers published in Age and Ageing to date are included. Finally, a group of papers that present innovative approaches to research in care homes, each of which give voice to residents and/or staff, are collated and presented as a way of moving towards a more resident and care home centred research agenda.
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Affiliation(s)
- Adam L Gordon
- Unit of Injury, Inflammation and Recovery, School of Medicine, University of Nottingham, Nottingham UK
- NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, UK
| | - Chloe Bennett
- Centre for Research in Public Health and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
| | - Claire Goodman
- Centre for Research in Public Health and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
- NIHR Applied Research Collaboration East of England (ARC EoE), Cambridge, UK
| | - Wilco P Achterberg
- The Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Molist-Brunet N, Sevilla-Sánchez D, González-Bueno J, Garcia-Sánchez V, Segura-Martín LA, Codina-Jané C, Espaulella-Panicot J. Therapeutic optimization through goal-oriented prescription in nursing homes. Int J Clin Pharm 2021; 43:990-997. [PMID: 33247821 PMCID: PMC8352828 DOI: 10.1007/s11096-020-01206-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 11/17/2020] [Indexed: 11/23/2022]
Abstract
Background People living in nursing homes are highly vulnerable and frail. Polypharmacy and inappropriate prescription (IP) are also common problems. Objectives The objectives of the study are (i) to study the baseline situation and calculate the frailty index (FI) of the residents, (ii) to assess the results of routine clinical practice to do a pharmacotherapy review (patient-centred prescription (PCP) model) (Molist Brunet et al., Eur Geriatr Med. 2015;6:565-9) and (iii) to study the relationship between IP and frailty, functional dependence, advanced dementia and end-of-life situation. Setting Two nursing homes in the same geographical area in Catalonia (Spain). Method This was a prospective, descriptive and observational study of elderly nursing home residents. Each patient's treatment was analysed by applying the PCP model, which centres therapeutic decisions on the patient's global assessment and individual therapeutic goal. Main outcome measure Prevalence of polypharmacy and IP. Results 103 patients were included. They were characterized by high multimorbidity and frailty. Up to 59.2% were totally dependent. At least one IP was identified in 92.2% of residents. Prior to the pharmacological review, the mean number of chronic medications prescribed per resident was 6.63 (SD 2.93) and after this review it was 4.97 (SD 2.88). Polypharmacy decreased from 72.55% to 52.94% and excessive polypharmacy fell from 18.62% to 5.88%.The highest prevalence of IP was detected in people with a higher FI, in those identified as end-of-life, and also in more highly dependent residents (p < 0.05). Conclusions People who live in nursing homes have an advanced frailty. Establishing individualized therapeutic objectives with the application of the PCP model enabled to detect 92.2% of IP. People who are frailer, are functionally more dependent and those who are end-of-life are prescribed with inappropriate medication more frequently.
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Affiliation(s)
- N Molist-Brunet
- Hospital Universitari de la Santa Creu de Vic, Vic, Barcelona, Spain.
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic-University of Vic-Central University of Catalonia (UVIC-UCC), C. Miquel Martí i Pol, 1, 08500, Vic, Spain.
| | - D Sevilla-Sánchez
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic-University of Vic-Central University of Catalonia (UVIC-UCC), C. Miquel Martí i Pol, 1, 08500, Vic, Spain
- Pharmacy Department, Hospital Universitari de Vic, Vic, Barcelona, Spain
| | - J González-Bueno
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic-University of Vic-Central University of Catalonia (UVIC-UCC), C. Miquel Martí i Pol, 1, 08500, Vic, Spain
- Pharmacy Department, Hospital Universitari de Vic, Vic, Barcelona, Spain
| | | | | | - C Codina-Jané
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic-University of Vic-Central University of Catalonia (UVIC-UCC), C. Miquel Martí i Pol, 1, 08500, Vic, Spain
- Pharmacy Department, Hospital Universitari de Vic, Vic, Barcelona, Spain
| | - J Espaulella-Panicot
- Hospital Universitari de la Santa Creu de Vic, Vic, Barcelona, Spain
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic-University of Vic-Central University of Catalonia (UVIC-UCC), C. Miquel Martí i Pol, 1, 08500, Vic, Spain
- Geriatric and Palliative Care Department, Hospital Universitari de Vic, Vic, Barcelona, Spain
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Ouslander JG, Reyes B, Yang Z, Engstrom G, Tappen R, Newman D, Huckfeldt PJ. Nursing home performance in a trial to reduce hospitalizations: Implications for future trials. J Am Geriatr Soc 2021; 69:2316-2326. [PMID: 34018181 DOI: 10.1111/jgs.17231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/29/2021] [Accepted: 04/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Experience in trials of implementing quality improvement (QI) programs in nursing homes (NHs) has been variable. Understanding the characteristics of NHs that demonstrate improvements during these trials is critical to improving NH care. DESIGN Secondary analysis of a randomized controlled trial of implementation of a QI program to reduce hospital transfers. PARTICIPANTS Seventy-one NHs that completed the 12-month trial INTERVENTION: Implementation included distance-learning strategies, involvement of a champion, regular submission of data on hospitalizations and root cause analyses of transfers, and training, feedback and support. MEASUREMENTS Primary outcomes included all-cause and potentially avoidable hospitalizations and emergency department (ED) visits per 1000 NH resident days, and the percentage of residents readmitted in 30-days. We compared multiple other variables that could influence effective program implementation in NHs in the highest versus lowest quartile of changes in the primary outcomes. RESULTS The 18 high-performing NHs had significant reductions in hospitalization and ED visits, whereas the 18 NHs in the low-performing group had increases. The difference in changes in each outcome varied between a reduction of 0.75 and 2.30 events relative to a NH with a census of 100; the absolute difference in 30-day readmissions was 19%. None of the variables we examined reached significance after adjustment for multiple comparisons between the groups. There was no consistent pattern of differences in nonprofit status, nursing staffing, and quality ratings. CONCLUSION Our experience and reviews of other NH trials suggest that key factors contributing to successful implementation QI programs in NHs remain unclear. To improve NH care, implementation trials should account for intervention fidelity and factors that have not been examined in detail, such as degree and nature of leadership support, financial and regulatory incentives, quality measures, resident and family perspectives, and the availability of onsite high-quality medical care and support of the medical director.
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Affiliation(s)
- Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA.,Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA
| | - Bernardo Reyes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Zhiyou Yang
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gabriella Engstrom
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Ruth Tappen
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA
| | - David Newman
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA
| | - Peter J Huckfeldt
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
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Pham T, Bugeja L, Holmes A, Ibrahim JE. Systematic Review of Randomized Controlled Trials in Australian Nursing Homes from 2000 to 2018. J Am Geriatr Soc 2020; 69:1086-1093. [PMID: 33216941 DOI: 10.1111/jgs.16944] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/12/2020] [Accepted: 10/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES High-quality research provides an evidence base for optimal practice care in clinical settings, yet, little is known about the nature and extent of randomized control trials (RCTs) conducted in Australian nursing homes (NHs). Research from other settings and other countries is not necessarily transferable to the Australian NH sector. We sought to identify and describe RCTs conducted in Australia which investigated interventions targeted at improving care for NH residents. DESIGN The design of this study comprised a systematic literature search with a narrative review. Studies were included if they were RCTs published after 2000, conducted in an Australian NH, and evaluated a health intervention which may have directly or indirectly benefitted the NH resident. SETTING Australian NHs. PARTICIPANTS Nursing home residents. MEASUREMENTS Jurisdiction (state or territory where the study was conducted), number of NHs recruited in each trial, number of residents included in each trial, intervention characteristics, comparator characteristics, and characteristics of outcome. RESULTS Only 43 articles reporting on 39 RCTs were identified. In contrast, 30 Australian musculoskeletal RCTs were published in just 2 years (2011-2012). Most of the RCTs identified were conducted in New South Wales (n = 14), Queensland (n = 10), and Victoria (n = 9). The mean number of NHs included in each trial was 22.4 (standard deviation (SD) = 27.0), with a median of 14.5 (interquartile range (IQR) = 27.8), while the mean number of residents included was 412.4 (SD = 921) with a median of 187 (IQR = 341.0). The most common interventions targeted: managing dementia (n = 20), prevention of falls (n = 7), and addressing mental health issues (n = 6). CONCLUSION This review provides evidence of the paucity of high-quality research in the form of RCTs, in the Australian NH setting and demonstrates the need for Australia to improve its research capability in the NH sector.
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Affiliation(s)
- Tony Pham
- Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lyndal Bugeja
- Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alice Holmes
- Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joseph E Ibrahim
- Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
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Chadborn NH, Devi R, Hinsliff-Smith K, Banerjee J, Gordon AL. Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes. Eur Geriatr Med 2020; 12:17-26. [PMID: 32888183 PMCID: PMC7472942 DOI: 10.1007/s41999-020-00389-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/26/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE We conducted a scoping review of quality improvement in care homes. We aimed to identify participating occupational groups and methods for evaluation. Secondly, we aimed to describe resident-level interventions and which outcomes were measured. METHODS Following extended PRISMA guideline for scoping reviews, we conducted systematic searches of Medline, CINAHL, Psychinfo, and ASSIA (2000-2019). Furthermore, we searched systematic reviews databases including Cochrane Library and JBI, and the grey literature database, Greylit. Four co-authors contributed to selection and data extraction. RESULTS Sixty five studies were included, 6 of which had multiple publications (75 articles overall). A range of quality improvement strategies were implemented, including audit feedback and quality improvement collaboratives. Methods consisted of controlled trials, quantitative time series and qualitative interview and observational studies. Process evaluations, involving staff of various occupational groups, described experiences and implementation measures. Many studies measured resident-level outputs and health outcomes. 14 studies reported improvements to a clinical measure; however, four of these articles were of low quality. Larger randomised controlled studies did not show statistically significant benefits to resident health outcomes. CONCLUSION In care homes, quality improvement has been applied with several different strategies, being evaluated by a variety of measures. In terms of measuring benefits to residents, process outputs and health outcomes have been reported. There was no pattern of which quality improvement strategy was used for which clinical problem. Further development of reporting of quality improvement projects and outcomes could facilitate implementation.
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Affiliation(s)
- Neil H Chadborn
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK. .,NIHR Applied Research Collaboration East Midlands, Nottingham, UK.
| | - Reena Devi
- School of Healthcare, University of Leeds, Leeds, UK
| | | | - Jay Banerjee
- School of Life Sciences, University of Leicester, Leicester, UK
| | - Adam L Gordon
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Applied Research Collaboration East Midlands, Nottingham, UK
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A Scoping Review on the Attributes of Cluster Randomized Controlled Trials in Long-Term Care Facilities. Curr Gerontol Geriatr Res 2020; 2020:6085368. [PMID: 32411218 PMCID: PMC7204357 DOI: 10.1155/2020/6085368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 11/04/2019] [Indexed: 11/28/2022] Open
Abstract
Cluster randomized trial design, where groups of participants are randomized instead of individual participants, is increasingly being used in long-term care research. The purpose of this review was to determine the characteristics of cluster randomized trials in long-term care facilities. A medical librarian conducted the literature search. Two independent reviewers reviewed each paper. Studies were included if the design was cluster randomized and participants were from long-term care facilities. For each included study, two independent data extractors captured data on study attributes, including: journal, location, year published, author discipline, funding, methodology, number of participants, and intervention target. The literature search yielded 7,679 unique studies, with 195 studies meeting the selection criteria and being included for data extraction. The included studies were published between 1976 and 2017, with 53% of studies published after 2009. The term cluster randomized was in the title of only 45% of the studies. The studies were conducted worldwide; the United States had the largest number of studies (23%), followed by the United Kingdom (18%). Ten percent of studies were published in journals with an impact factor >10. The most frequent discipline of the first and last authors was medicine (34%), followed by nursing (17%). Forty-nine percent of the studies had government funding, while only 20% had medical industry funding. In studies with <1000 residents, 85% of the studies obtained consent from the resident and/or their proxy, while in studies with ≥ 1000 residents, it was 31%. The most frequent intervention targets were infection (13%), falls/fracture (13%), and behavior/physical restraint (13%). Cluster randomized controlled trials in long-term care have a unique set of characteristics. Results of this review will provide guidance to researchers conducting studies in long-term care facilities.
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Bunn F, Goodman C, Corazzini K, Sharpe R, Handley M, Lynch J, Meyer J, Dening T, Gordon AL. Setting Priorities to Inform Assessment of Care Homes' Readiness to Participate in Healthcare Innovation: A Systematic Mapping Review and Consensus Process. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E987. [PMID: 32033293 PMCID: PMC7037621 DOI: 10.3390/ijerph17030987] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/26/2020] [Accepted: 01/31/2020] [Indexed: 11/16/2022]
Abstract
Organisational context is known to impact on the successful implementation of healthcare initiatives in care homes. We undertook a systematic mapping review to examine whether researchers have considered organisational context when planning, conducting, and reporting the implementation of healthcare innovations in care homes. Review data were mapped against the Alberta Context Tool, which was designed to assess organizational context in care homes. The review included 56 papers. No studies involved a systematic assessment of organisational context prior to implementation, but many provided post hoc explanations of how organisational context affected the success or otherwise of the innovation. Factors identified to explain a lack of success included poor senior staff engagement, non-alignment with care home culture, limited staff capacity to engage, and low levels of participation from health professionals such as general practitioners (GPs). Thirty-five stakeholders participated in workshops to discuss findings and develop questions for assessing care home readiness to participate in innovations. Ten questions were developed to initiate conversations between innovators and care home staff to support research and implementation. This framework can help researchers initiate discussions about health-related innovation. This will begin to address the gap between implementation theory and practice.
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Affiliation(s)
- Frances Bunn
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire AL10 9AB, UK; (R.S.); (M.H.)
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire AL10 9AB, UK; (R.S.); (M.H.)
| | | | - Rachel Sharpe
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire AL10 9AB, UK; (R.S.); (M.H.)
| | - Melanie Handley
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire AL10 9AB, UK; (R.S.); (M.H.)
| | - Jennifer Lynch
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire AL10 9AB, UK; (R.S.); (M.H.)
| | - Julienne Meyer
- Care for Older People, City, University of London, London EC1V OHB, UK;
| | - Tom Dening
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham NG7 2TU, UK;
| | - Adam L Gordon
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby DE22 3NE, UK;
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Gordon AL. Long-term care facilities and research: how COVID-19 changes things. GERIATRICS, GERONTOLOGY AND AGING 2020. [DOI: 10.5327/z2447-21232020v14n4edt2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Donaldson AIC, Smith TO, Alder S, Johnstone AM, De Roos B, Aucott LS, Gordon AL, Myint PK. Effect of nonmeat, high-protein supplementation on quality of life and clinical outcomes in older residents of care homes: a systematic review and meta-analysis. Nutr Rev 2018; 77:116-127. [DOI: 10.1093/nutrit/nuy061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alison I C Donaldson
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
- Academic Department of Medicine for the Elderly, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom
| | - Toby O Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Alder
- Academic Department of Medicine for the Elderly, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom
| | - Alexandra M Johnstone
- Rowett Institute of Nutrition and Health, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Baukje De Roos
- Rowett Institute of Nutrition and Health, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Lorna S Aucott
- Medical Statistics Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Adam L Gordon
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Phyo K Myint
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
- Academic Department of Medicine for the Elderly, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom
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Goodman C, Norton C, Buswell M, Russell B, Harari D, Harwood R, Roe B, Rycroft-Malone J, Drennan VM, Fader M, Maden M, Cummings K, Bunn F. Managing Faecal INcontinence in people with advanced dementia resident in Care Homes (FINCH) study: a realist synthesis of the evidence. Health Technol Assess 2018; 21:1-220. [PMID: 28805188 DOI: 10.3310/hta21420] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes. OBJECTIVE To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes. DESIGN A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders. DATA SOURCES The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register. RESULTS The scoping identified six programme theories with related context-mechanism-outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, there is limited value in focusing solely on FI or on single causes of FI such as constipation. Clinical assessment, knowledge of the causes of FI and strategies that recognise the individuals' preferences are necessary contextual factors. Valuing the intimate and personal care work that care home staff provide to people living with dementia and addressing the dementia-related challenges when providing continence care within the daily work routines are key to helping to reduce and manage FI in this population. LIMITATIONS The synthesis was constrained by limited evidence specific to FI and people with dementia in care homes and by the lack of dementia-specific evidence on continence aids. CONCLUSIONS This realist synthesis provides a theory-driven understanding of the conditions under which improvement in care for care home residents living with dementia and FI is likely to be successful. FUTURE WORK Future multicomponent interventions need to take account of how the presence of dementia affects the behaviours and choices of those delivering and receiving continence care within a care home environment. STUDY REGISTRATION This study is registered as PROSPERO CRD42014009902. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Marina Buswell
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Bridget Russell
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Danielle Harari
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Health and Social Care, King's College London, London, UK
| | - Rowan Harwood
- Health Care of Older People, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Brenda Roe
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK
| | | | - Vari M Drennan
- Centre for Health and Social Care Research, Faculty of Health, Social Care and Education, Kingston and St George's, London, UK
| | - Mandy Fader
- Health Sciences, University of Southampton, Southampton, UK
| | - Michelle Maden
- School of Health Sciences, University of Liverpool, Liverpool, UK
| | | | - Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
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Affiliation(s)
- Bill Matney
- Division of Music Education and Music Therapy, University of Kansas, Lawrence, KS, USA
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Easton T, Milte R, Crotty M, Ratcliffe J. Advancing aged care: a systematic review of economic evaluations of workforce structures and care processes in a residential care setting. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2016; 14:12. [PMID: 27999476 PMCID: PMC5153687 DOI: 10.1186/s12962-016-0061-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 11/29/2016] [Indexed: 11/30/2022] Open
Abstract
Long-term care for older people is provided in both residential and non-residential settings, with residential settings tending to cater for individuals with higher care needs. Evidence relating to the costs and effectiveness of different workforce structures and care processes is important to facilitate the future planning of residential aged care services to promote high quality care and to enhance the quality of life of individuals living in residential care. A systematic review conducted up to December 2015 identified 19 studies containing an economic component; seven included a complete economic evaluation and 12 contained a cost analysis only. Key findings include the potential to create cost savings from a societal perspective through enhanced staffing levels and quality improvement interventions within residential aged care facilities, while integrated care models, including the integration of health disciplines and the integration between residents and care staff, were shown to have limited cost-saving potential. Six of the 19 identified studies examined dementia-specific structures and processes, in which person-centred interventions demonstrated the potential to reduce agitation and improve residents’ quality of life. Importantly, this review highlights methodological limitations in the existing evidence and an urgent need for future research to identify appropriate and meaningful outcome measures that can be used at a service planning level.
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Affiliation(s)
- Tiffany Easton
- Flinders Health Economics Group, Flinders University, Adelaide, Australia ; NHMRC Partnership Centre on Dealing with Cognitive and Related Functional Decline in Older People, University of Sydney, Sydney, Australia ; Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, Australia
| | - Rachel Milte
- NHMRC Partnership Centre on Dealing with Cognitive and Related Functional Decline in Older People, University of Sydney, Sydney, Australia ; Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, Australia
| | - Maria Crotty
- NHMRC Partnership Centre on Dealing with Cognitive and Related Functional Decline in Older People, University of Sydney, Sydney, Australia ; Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, Australia
| | - Julie Ratcliffe
- Flinders Health Economics Group, Flinders University, Adelaide, Australia ; NHMRC Partnership Centre on Dealing with Cognitive and Related Functional Decline in Older People, University of Sydney, Sydney, Australia
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Menezes AV, Aguiar ADSD, Alves EF, Quadros LBD, Bezerra PP. Efetividade de uma intervenção fisioterapêutica cognitivo-motora em idosos institucionalizados com comprometimento cognitivo leve e demência leve. CIENCIA & SAUDE COLETIVA 2016; 21:3459-3467. [DOI: 10.1590/1413-812320152111.17892015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 12/17/2015] [Indexed: 11/22/2022] Open
Abstract
Resumo O objetivo desta pesquisa foi verificar a efetividade de quatro meses de intervenção fisioterapêutica cognitivo-motora, com frequência semanal única, na cognição, mobilidade e independência funcional de idosos com comprometimento cognitivo e demência leves residentes em instituição. Sob um ensaio clínico controlado, 15 sujeitos foram alocados entre grupo experimental (GE) e controle (GC). Para avaliação dos sujeitos foram aplicados os instrumentos: Mini-Exame do Estado Mental, Teste de Fluência Verbal e Bateria de Avaliação Frontal para análise das funções cognitivas; Escala de Equilíbrio Funcional de Berg e Teste Timed Up and Go para verificação da mobilidade, e Escala de Barthel e Índice de Pfeffer para mensuração da independência funcional. O procedimento estatístico envolveu a aplicação do teste t de Student, sob significância de 5%. Quanto aos resultados, o GE apresentou melhor desempenho apenas nos testes relacionados à mobilidade ao final da intervenção (p < 0,05). A intervenção proposta apresentou eficácia sobre a mobilidade, mas não na cognição e independência funcional. O curto período de tempo e a baixa frequência semanal podem estar relacionados aos resultados obtidos.
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Effective health care for older people living and dying in care homes: a realist review. BMC Health Serv Res 2016; 16:269. [PMID: 27422733 PMCID: PMC4947336 DOI: 10.1186/s12913-016-1493-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 06/29/2016] [Indexed: 11/10/2022] Open
Abstract
Background Care home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes. Methods We conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group. Results Strategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change. Conclusion How relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.
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Bainbridge D, Seow H, Sussman J, Pond G. Factors associated with acute care use among nursing home residents dying of cancer: a population-based study. Int J Palliat Nurs 2015. [PMID: 26203955 DOI: 10.12968/ijpn.2015.21.7.349] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Little is known about residents of long-term care (LTC) facilities who die of cancer. The authors examined factors among this cohort prognostic of greater acute care use to identify areas for improving support in LTC. METHODS The authors used administrative data representing all cancer decedents in Ontario, Canada, who had been living in LTC. Binary logistic regression was used to examine the contribution of covariates to having an emergency department (ED) visit in the last 6 months of life or to death in hospital. RESULTS Among the 1196 LTC residents in the study cohort, 61% had visited an ED in the last 6 months of life and 20% had died in hospital. Cancer type, income, gender, time in LTC and rural location were not strong predictors of the acute care outcomes. However, certain comorbidities, being younger and region of residence significantly increased the odds of an ED visit and/or hospital death (all P<0.05). CONCLUSIONS Determining the characteristics of LTC patients more likely to access acute care services can help to inform interventions that avoid costly and potentially adverse transfers to hospital. The study of cancer patients in LTC represents a starting point for clarifying the potential of specialised palliative care nursing and other support that is often lacking in these facilities.
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Affiliation(s)
- Daryl Bainbridge
- Senior Research Coordinator, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Hsien Seow
- Associate Professor, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Jonathan Sussman
- Associate Professor, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Gregory Pond
- Associate Professor; all at Department of Oncology, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
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Goodman C, Rycroft Malone J, Norton C, Harari D, Harwood R, Roe B, Russell B, Fader M, Buswell M, Drennan VM, Bunn F. Reducing and managing faecal incontinence in people with advanced dementia who are resident in care homes: protocol for a realist synthesis. BMJ Open 2015; 5:e007728. [PMID: 26163032 PMCID: PMC4499729 DOI: 10.1136/bmjopen-2015-007728] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Faecal incontinence (FI) is the involuntary loss of liquid or solid stool that is a social or hygienic problem. The prevalence of FI in residents of care homes is high, but it is not an inevitable consequence of old age or dementia. There is good evidence on risk factors, but few studies provide evidence about effective interventions. There is a need to understand how, why, and in what circumstances particular programmes to reduce and manage FI are effective (or not) for people with dementia. The purpose of this review is to identify which (elements of the) interventions could potentially be effective, and examine the barriers and facilitators to the acceptability, uptake and implementation of interventions designed to address FI in people with dementia who are resident in care homes. METHODS AND ANALYSIS A realist synthesis approach to review the evidence will be used which will include studies on continence, person-centred care, implementation research in care homes, workforce and research on care home culture. An iterative four-stage approach is planned. Phase 1: development of an initial programme theory or theories that will be 'tested' through a first scoping of the literature and consultation with five stakeholder groups (care home providers, user representatives, academics and practice educators, clinicians with a special interest in FI and continence specialists). Phase 2: a systematic search and analysis of published and unpublished evidence to test and develop the programme theories identified in phase 1. Phase 3: validation of programme theory/ies with a purposive sample of participants from phase 1. ETHICS AND DISSEMINATION The overall protocol does not require ethical review. The University research ethics committee will review interviews conducted as part of phase 1 and 3. The final fourth phase will synthesise and develop recommendations for practice and develop testable hypotheses for further research.
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Affiliation(s)
- Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Jo Rycroft Malone
- School of Healthcare Sciences, Bangor University School of Health Care Sciences, Bangor, UK
| | - Christine Norton
- Florence Nightingale School of Nursing & Midwifery, King's College London, London, UK
| | - Danielle Harari
- Division of Health and Social Care, Department of Ageing and Health, Guys and St Thomas’, King's College London, London, UK
| | - Rowan Harwood
- Health Care of Older People Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Brenda Roe
- Faculty of Health and Social Care, Edge Hill University of Manchester, Manchester, UK
| | - Bridget Russell
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Mandy Fader
- Department of Health Sciences, University of Southampton, Southampton, UK
| | - Marina Buswell
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Vari M Drennan
- Faculty of Health, Social Care and Education, St Georges University of London and Kingston University, UK
| | - Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
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Gladman J, Harwood R, Conroy S, Logan P, Elliott R, Jones R, Lewis S, Dyas J, Schneider J, Porock D, Pollock K, Goldberg S, Edmans J, Gordon A, Bradshaw L, Franklin M, Whittamore K, Robbins I, Dunphy A, Spencer K, Darby J, Tanajewski L, Berdunov V, Gkountouras G, Foster P, Frowd N. Medical Crises in Older People: cohort study of older people attending acute medical units, developmental work and randomised controlled trial of a specialist geriatric medical intervention for high-risk older people; cohort study of older people with mental health problems admitted to hospital, developmental work and randomised controlled trial of a specialist medical and mental health unit for general hospital patients with delirium and dementia; and cohort study of residents of care homes and interview study of health-care provision to residents of care homes. PROGRAMME GRANTS FOR APPLIED RESEARCH 2015. [DOI: 10.3310/pgfar03040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundThis programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents.MethodsIn the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems in a general hospital, developed a specialist unit to care for them and tested the unit in a randomised controlled trial (Trial of an Elderly Acute care Medical and mental health unit; TEAM). In the third workstream we undertook a literature review, a cohort study of a representative sample of care home residents and a qualitative study of the delivery of health care to care home residents.ResultsAlthough 222 of the 433 (51%) patients recruited to the AMIGOS study were vulnerable enough to be readmitted within 3 months, the trial showed no clinical benefit of interface geriatricians over usual care and they were not cost-effective. The TEAM study recruited 600 patients and there were no significant benefits of the specialist unit over usual care in terms of mortality, institutionalisation, mental or functional outcomes, or length of hospital stay, but there were significant benefits in terms of patient experience and carer satisfaction with care. The medical and mental health unit was cost-effective. The care home workstream found that the organisation of health care for residents in the UK was variable, leaving many residents, whose health needs are complex and unpredictable, at risk of poor health care. The variability of health care was explained by the variability in the types and sizes of homes, the training of care home staff, the relationships between care home staff and the primary care doctors and the organisation of care and training among primary care doctors.DiscussionThe interface geriatrician intervention was not sufficient to alter clinical outcomes and this might be because it was not multidisciplinary and well integrated across the secondary care–primary care interface. The development and evaluation of multidisciplinary and better-integrated models of care is justified. The specialist unit improved the quality of experience of patients with delirium and dementia in general hospitals. Despite the need for investment to develop such a unit, the unit was cost-effective. Such units provide a model of care for patients with dementia and delirium in general hospitals that requires replication. The health status of, and delivery of health care to, care home residents is now well understood. Models of care that follow the principles of comprehensive geriatric assessment would seem to be required, but in the UK these must be sufficient to take account of the current provision of primary health care and must recognise the importance of the care home staff in the identification of health-care needs and the delivery of much of that care.Trial registrationCurrent Controlled Trials ISRCTN21800480 (AMIGOS); ClinicalTrials.gov NCT01136148 (TEAM).FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 3, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- John Gladman
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Rowan Harwood
- Health Care of Older People, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, UK
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Pip Logan
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Rachel Elliott
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Rob Jones
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Jane Dyas
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Justine Schneider
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Davina Porock
- University at Buffalo School of Nursing, Buffalo, NY, USA
| | - Kristian Pollock
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sarah Goldberg
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Judi Edmans
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Adam Gordon
- Health Care of Older People, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, UK
| | - Lucy Bradshaw
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Matthew Franklin
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Katherine Whittamore
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Isabella Robbins
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Aidan Dunphy
- Clinical Research Unit, Leicester Royal Infirmary, Leicester, UK
| | - Karen Spencer
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Janet Darby
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Lukasz Tanajewski
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Vladislav Berdunov
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Georgios Gkountouras
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Pippa Foster
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Nadia Frowd
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
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22
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Sales AE, Schalm C, Baylon MAB, Fraser KD. Data for improvement and clinical excellence: report of an interrupted time series trial of feedback in long-term care. Implement Sci 2014; 9:161. [PMID: 25384801 PMCID: PMC4230368 DOI: 10.1186/s13012-014-0161-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 10/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is considerable evidence about the effectiveness of audit coupled with feedback for provider behavior change, although few feedback interventions have been conducted in long-term care settings. The primary purpose of the Data for Improvement and Clinical Excellence-Long-Term Care (DICE-LTC) project was to assess the effects of a feedback intervention delivered to all direct care providers on resident outcomes. Our objective in this report is to assess the effect of feedback reporting on rates of pain assessment, depression screening, and falls over time. METHODS The intervention consisted of monthly feedback reports delivered to all direct care providers, facility and unit administrators, and support staff, delivered over 13 months in nine LTC units across four facilities. Data for feedback reports came from the Resident Assessment Instrument Minimum Data Set (RAI) version 2.0, a standardized instrument mandated in LTC facilities throughout Alberta. The primary evaluation used an interrupted time series design with a comparison group (units not included in the feedback intervention) and a comparison condition (pressure ulcers). We used segmented regression analysis to assess the effect of the feedback intervention. RESULTS The primary outcome of the study, falls, showed little change over the period of the intervention, except for a small increase in the rate of falls during the intervention period. The only outcome that improved during the intervention period was the proportion of residents with high pain scores, which decreased at the beginning of the intervention. The proportion of residents with high depression scores appeared to worsen during the intervention. CONCLUSIONS Maintaining all nine units in the study for its 13-month duration was a positive outcome. The feedback reports, without any other intervention included, did not achieve the desired reduction in proportion of falls and elevated depression scores. The survey on intention to change pain assessment practice which was conducted shortly after most of the feedback distribution cycles may have acted as a co-intervention supporting a reduction in pain scores. The processing and delivery of feedback reports could be accomplished at relatively low cost because the data are mandated and could be added to other intervention approaches to support implementation of evidence-based practices.
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Affiliation(s)
- Anne E Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. .,Division of Nursing Business and Health Systems, School of Nursing, University of Michigan, 400 N. Ingalls Street, Ann Arbor, MI, 48109-5482, USA.
| | | | | | - Kimberly D Fraser
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.
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23
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Connolly MJ, Boyd M, Broad JB, Kerse N, Lumley T, Whitehead N, Foster S. The Aged Residential Care Healthcare Utilization Study (ARCHUS): a multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities. J Am Med Dir Assoc 2014; 16:49-55. [PMID: 25239019 DOI: 10.1016/j.jamda.2014.07.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 07/01/2014] [Accepted: 07/09/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess effect of a complex, multidisciplinary intervention aimed at reducing avoidable acute hospitalization of residents of residential aged care (RAC) facilities. DESIGN Cluster randomized controlled trial. SETTING RAC facilities with higher than expected hospitalizations in Auckland, New Zealand, were recruited and randomized to intervention or control. PARTICIPANTS A total of 1998 residents of 18 intervention facilities and 18 control facilities. INTERVENTION A facility-based complex intervention of 9 months' duration. The intervention comprised gerontology nurse specialist (GNS)-led staff education, facility bench-marking, GNS resident review, and multidisciplinary (geriatrician, primary-care physician, pharmacist, GNS, and facility nurse) discussion of residents selected using standard criteria. MAIN OUTCOME MEASURES Primary end point was avoidable hospitalizations. Secondary end points were all acute admissions, mortality, and acute bed-days. Follow-up was for a total of 14 months. RESULTS The intervention did not affect main study end points: number of acute avoidable hospital admissions (RR 1.07; 95% CI 0.85-1.36; P = .59) or mortality (RR 1.11; 95% CI 0.76-1.61; P = .62). CONCLUSIONS This multidisciplinary intervention, packaging selected case review, and staff education had no overall impact on acute hospital admissions or mortality. This may have considerable implications for resourcing in the acute and RAC sectors in the face of population aging. Australian and New Zealand Clinical Trials Registry (ACTRN12611000187943).
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Affiliation(s)
- Martin J Connolly
- Freemasons' Department of Geriatric Medicine, University of Auckland, Takapuna, Auckland, New Zealand; Waitemata District Health Board, Auckland, New Zealand.
| | - Michal Boyd
- Freemasons' Department of Geriatric Medicine, University of Auckland, Takapuna, Auckland, New Zealand; Waitemata District Health Board, Auckland, New Zealand; Department of Nursing, University of Auckland, Auckland, New Zealand
| | - Joanna B Broad
- Freemasons' Department of Geriatric Medicine, University of Auckland, Takapuna, Auckland, New Zealand
| | - Ngaire Kerse
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Thomas Lumley
- Department of Statistics, University of Auckland, Auckland, New Zealand
| | | | - Susan Foster
- Freemasons' Department of Geriatric Medicine, University of Auckland, Takapuna, Auckland, New Zealand
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24
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The optimal study: describing the key components of optimal health care delivery to UK care home residents: a research protocol. J Am Med Dir Assoc 2014; 15:681-6. [PMID: 25086691 DOI: 10.1016/j.jamda.2014.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/12/2014] [Accepted: 06/13/2014] [Indexed: 11/23/2022]
Abstract
Long-term institutional care in the United Kingdom is provided by care homes. Residents have prevalent cognitive impairment and disability, have multiple diagnoses, and are subject to polypharmacy. Prevailing models of health care provision (ad hoc, reactive, and coordinated by general practitioners) result in unacceptable variability of care. A number of innovative responses to improve health care for care homes have been commissioned. The organization of health and social care in the United Kingdom is such that it is unlikely that a single solution to the problem of providing quality health care for care homes will be identified that can be used nationwide. Realist evaluation is a methodology that uses both qualitative and quantitative data to establish an in-depth understanding of what works, for whom, and in what settings. In this article we describe a protocol for using realist evaluation to understand the context, mechanisms, and outcomes that shape effective health care delivery to care home residents in the United Kingdom. By describing this novel approach, we hope to inform international discourse about research methodologies in long-term care settings internationally.
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Davies SL, Goodman C, Manthorpe J, Smith A, Carrick N, Iliffe S. Enabling research in care homes: an evaluation of a national network of research ready care homes. BMC Med Res Methodol 2014; 14:47. [PMID: 24708761 PMCID: PMC4021218 DOI: 10.1186/1471-2288-14-47] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 03/31/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the UK care homes are one of the main providers of long term care for older people with dementia. Despite the recent increase in care home research, residents with dementia are often excluded from studies. Care home research networks have been recommended by the Ministerial Advisory Group on Dementia Research (MAGDR) as a way of increasing research opportunities for residents with dementia. This paper reports on an evaluation of the feasibility and early impact of an initiative to increase care home participation in research. METHODS A two phase, mixed methods approach was used; phase 1 established a baseline of current and recent studies including the National Institute for Health Research portfolio. To explore the experiences of recruiting care homes and research participation, interviews were conducted with researchers working for the Dementia and Neurodegenerative Diseases Research Network (DeNDRoN) and care home managers. In phase 2, four DeNDRoN area offices recruited care homes to a care home network for their region. The care home networks were separate from the DeNDRoN research network. Diaries were used to document and cost recruitment; DeNDRoN staff were interviewed to understand the barriers, facilitators and impact of the care home networks. RESULTS Thirty three current or recent studies were identified as involving care homes as care home specific studies or those which included residents. Further details of care home recruitment were obtained on 20 studies by contacting study teams. Care home managers were keen to be involved in research that provided staff support, benefits for residents and with minimal disruption. In phase 2, 141 care homes were recruited to the care home research networks, through corporate engagement and individual invitation. Pre-existing relationships with care homes facilitated recruitment. Sites with minimal experience of working with care homes identified the need for care home training for researchers. CONCLUSIONS Phase 1 review revealed a small but increasing number of studies involving care homes. Phase 2 demonstrated the feasibility of care home research networks, their potential to increase recruitment to research and develop partnerships between health services and care homes, but highlighted the need for care home training for researchers.
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Affiliation(s)
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield AL10 9AB, UK.
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26
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Reducing hospital admissions from nursing homes: a systematic review. BMC Health Serv Res 2014; 14:36. [PMID: 24456561 PMCID: PMC3906881 DOI: 10.1186/1472-6963-14-36] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 01/21/2014] [Indexed: 11/18/2022] Open
Abstract
Background The geriatric nursing home population is vulnerable to acute and deteriorating illness due to advanced age, multiple chronic illnesses and high levels of dependency. Although the detriments of hospitalising the frail and old are widely recognised, hospital admissions from nursing homes remain common. Little is known about what alternatives exist to prevent and reduce hospital admissions from this setting. The objective of this study, therefore, is to summarise the effects of interventions to reduce acute hospitalisations from nursing homes. Methods A systematic literature search was performed in Cochrane Library, PubMed, MEDLINE, EMBASE and ISI Web of Science in April 2013. Studies were eligible if they had a geriatric nursing home study population and were evaluating any type of intervention aiming at reducing acute hospital admission. Systematic reviews, randomised controlled trials, quasi randomised controlled trials, controlled before-after studies and interrupted time series were eligible study designs. The process of selecting studies, assessing them, extracting data and grading the total evidence was done by two researchers individually, with any disagreement solved by a third. We made use of meta-analyses from included systematic reviews, the remaining synthesis is descriptive. Based on the type of intervention, the included studies were categorised in: 1) Interventions to structure and standardise clinical practice, 2) Geriatric specialist services and 3) Influenza vaccination. Results Five systematic reviews and five primary studies were included, evaluating a total of 11 different interventions. Fewer hospital admissions were found in four out of seven evaluations of structuring and standardising clinical practice; in both evaluations of geriatric specialist services, and in influenza vaccination of residents. The quality of the evidence for all comparisons was of low or very low quality, using the GRADE approach. Conclusions Overall, eleven interventions to reduce hospital admissions from nursing homes were identified. None of them were tested more than once and the quality of the evidence was low for every comparison. Still, several interventions had effects on reducing hospital admissions and may represent important aspects of nursing home care to reduce hospital admissions.
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Abstract
Care home medicine has been an under-researched area, but over the last decade there has been a substantial growth in publications. Most of these have focused on the 'geriatric giants' of falls, incontinence and mental health issues (especially dementia, behavioural disturbance and depression) as well as other key topics such as medication use and issues related to death and dying. Other areas of recent interest are around access to health services for care home residents, how such services may most effectively be developed and how the quality of life for residents can be enhanced. While many of the reported studies are small and not always well designed, evidence in several areas is emerging which begins to guide service developments. A common theme is that multi-disciplinary interventions are the most effective models of delivery. The role of care home staff as members of these teams is key to their effectiveness. Recent consensus guidelines around falls prevention in care homes synthesise the evidence and recommend multi-disciplinary interventions, and clarify the role of vitamin D and of exercise in certain populations in the care home. The benefits of pharmacist led medication reviews are beginning to emerge; although studies reviewed to date have not yet led to the 'holy grail' of hospital admission avoidance they point to benefits in reduction of drug burden. Effectiveness may be enhanced when working with GPs and care home nurses. Welcome evidence is emerging that in the UK the rate of prescription of anti-psychotics has fallen. This is clear evidence that changes in practice around care homes can be effected. The poor access to non-pharmacological therapies for care home residents with behavioural disturbance remains a significant gap in service. End-of-life care planning and delivery is an important part of care in care homes, and there is evidence that integrated pathways can improve care; however, the use of palliative care medications was limited unless specialist care staff were involved. Integrated models of care that focus on resident-centred goals and which value the role of care home staff as members of the team working to deliver these goals are most likely to result in improvements in the quality of care experienced by care home residents.
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Affiliation(s)
- Eileen Burns
- Department Medicine for the Elderly, St James's Hospital, Beckett St, Leeds LS9 7TF, UK
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28
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Welsh T, Gladman J, Gordon AL. The treatment of hypertension in care home residents: a systematic review of observational studies. J Am Med Dir Assoc 2013; 15:8-16. [PMID: 23969079 DOI: 10.1016/j.jamda.2013.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 06/28/2013] [Indexed: 11/15/2022]
Abstract
AIM To describe the prevalence of hypertension in care home residents, its treatment, change in treatment over time, and the achievement of blood pressure (BP) control. METHOD The PubMed, Cochrane, Embase, and PsychINFO databases were searched for observational studies involving care home residents with a diagnosis of hypertension. The search was limited to English language articles involving adults and humans published from 1990 onward. Abstracts and titles were reviewed with eligible articles read in full. Bibliographies were examined for further relevant studies. The final selection of studies was then analyzed and appraised. RESULTS Sixteen articles were identified for analysis, of which half were studies carried out in the United States. The prevalence of hypertension in care home residents was 35% (range 16%-71%); 72% of these were on at least 1 antihypertensive (mean 1.5 antihypertensives per individual), with diuretics being the most common. The prevalence of hypertension in study populations was greater in more recent studies (P = .004). ACEi/ARBs (P = .001) and β-blockers (P = .04) were prescribed more frequently in recent studies, whereas use of calcium-channel blockers and diuretics remained unchanged over time. The number of antihypertensives prescribed per patient was higher (correlation 0.332, P = .009), whereas fewer patients achieved target BP (correlation -0.671, P = .099) in more recent studies. CONCLUSION Hypertension is common in care home residents and is commonly treated with antihypertensive drugs, which were prescribed more frequently in more recent studies but with no better BP control. These studies indicate a tendency toward increasing polypharmacy over time, with associated risk of adverse events, without demonstrable benefit in terms of BP control.
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Affiliation(s)
- Tomas Welsh
- Division of Rehabilitation and Ageing, School of Community Health Sciences, University of Nottingham, Nottingham, UK.
| | - John Gladman
- Division of Rehabilitation and Ageing, School of Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Adam L Gordon
- Division of Rehabilitation and Ageing, School of Community Health Sciences, University of Nottingham, Nottingham, UK
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