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Min D, Kim S. Development and validation of the resident safety activity questionnaire for long-term care facility staff. Geriatr Nurs 2024; 56:278-284. [PMID: 38402807 DOI: 10.1016/j.gerinurse.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 01/31/2024] [Accepted: 02/05/2024] [Indexed: 02/27/2024]
Abstract
This study developed and tested a questionnaire to evaluate the safety activities supporting older adult residents' quality of care among long-term care facility staff. The process included item construction, expert review and pilot testing, testing of reliability and validation with 268 staff from 12 targeted facilities in South Korea. The final questionnaire yielded 28 items across six domains: proactive activities for emergency situations, comfort management, prevention of infections, staff training and communication, sufficient goods and equipment, and adequate personnel. These factors explained 73.48 % of the total variance. The fit indices in the confirmatory factor analysis were acceptable, and the total Cronbach's ⍺ was 0.952 (sub-domains: 0.823 - .895), indicating high reliability. The findings suggest the reliability and validity of the newly-developed Resident Safety Activity Questionnaire, enabling an accurate evaluation of the safety of long-term care facility residents and serving as an indicator for improving care quality in such establishments.
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Affiliation(s)
- Deulle Min
- Department of Nursing, College of Medicine, Wonkwang University, Iksan, Republic of Korea
| | - Suhee Kim
- School of Nursing and Research Institute of Nursing Science, Hallym University, Chuncheon, Republic of Korea.
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Cao Y, Liu C, Lin J, Ng L, Needleman I, Walsh T, Li C. Oral care measures for preventing nursing home-acquired pneumonia. Cochrane Database Syst Rev 2022; 11:CD012416. [PMID: 36383760 PMCID: PMC9668328 DOI: 10.1002/14651858.cd012416.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pneumonia in residents of nursing homes can be termed nursing home-acquired pneumonia (NHAP). NHAP is one of the most common infections identified in nursing home residents and has the highest mortality of any infection in this population. NHAP is associated with poor oral hygiene and may be caused by aspiration of oropharyngeal flora into the lung. Oral care measures to remove or disrupt oral plaque might reduce the risk of NHAP. This is the first update of a review published in 2018. OBJECTIVES To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities. SEARCH METHODS An information specialist searched CENTRAL, MEDLINE, Embase, one other database and three trials registers up to 12 May 2022. We also used additional search methods to identify published, unpublished and ongoing studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated the effects of oral care measures (brushing, swabbing, denture cleaning mouthrinse, or combination) in residents of any age in nursing homes and other long-term care facilities. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed search results, extracted data, and assessed risk of bias in the included studies. We contacted study authors for additional information. We pooled data from studies with similar interventions and outcomes. We reported risk ratios (RRs) for dichotomous outcomes, mean differences (MDs) for continuous outcomes, and hazard ratios (HRs) or incidence rate ratio (IRR) for time-to-event outcomes, using random-effects models. MAIN RESULTS We included six RCTs (6244 participants), all of which were at high risk of bias. Three studies were carried out in Japan, two in the USA, and one in France. The studies evaluated one comparison: professional oral care versus usual oral care. We did not include the results from one study (834 participants) because it had been stopped at interim analysis. Consistent results from five studies, with 5018 participants, provided insufficient evidence of a difference between professional oral care and usual (simple, self-administered) oral care in the incidence of pneumonia. Three studies reported HRs, one reported IRRs, and one reported RRs. Due to the variation in study design and follow-up duration, we decided not to pool the data. We downgraded the certainty of the evidence for this outcome by two levels to low: one level for study limitations (high risk of performance bias), and one level for imprecision. There was low-certainty evidence from meta-analysis of two individually randomised studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24 months' follow-up (RR 0.43, 95% CI 0.25 to 0.76, 454 participants). Another study (2513 participants) reported insufficient evidence of a difference for this outcome at 18 months' follow-up. Three studies measured all-cause mortality and identified insufficient evidence of a difference between professional and usual oral care at 12 to 30 months' follow-up. Only one study (834 participants) measured the adverse effects of the interventions. The study identified no serious events and 64 non-serious events, the most common of which were oral cavity disturbances (not defined) and dental staining. No studies evaluated oral care versus no oral care. AUTHORS' CONCLUSIONS Although low-certainty evidence suggests that professional oral care may reduce mortality compared to usual care when measured at 24 months, the effect of professional oral care on preventing NHAP remains largely unclear. Low-certainty evidence was inconclusive about the effects of this intervention on incidence and number of first episodes of NHAP. Due to differences in study design, effect measures, follow-up duration, and composition of the interventions, we cannot determine the optimal oral care protocol from current evidence. Future trials will require larger samples, robust methods that ensure low risk of bias, and more practicable interventions for nursing home residents.
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Affiliation(s)
- Yubin Cao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Chang Liu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jie Lin
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Anaesthesiology and Intensive Care Unit, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Linda Ng
- School of Nursing and Midwifery, The University of Queensland, South Brisbane, Australia
| | - Ian Needleman
- Unit of Periodontology and International Centre for Evidence-Based Oral Health, UCL Eastman Dental Institute, London, UK
| | - Tanya Walsh
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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Pneumonia, Aspiration Pneumonia, or Frailty-Associated Pneumonia? Geriatrics (Basel) 2022; 7:geriatrics7050115. [PMID: 36286218 PMCID: PMC9602119 DOI: 10.3390/geriatrics7050115] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/17/2022] Open
Abstract
Pneumonia is a common reason for admission afflicting frail older adults. Those who are the frailest are more likely to be provided with a diagnosis of aspiration pneumonia. This diagnosis has no clear definition and no clinical consensus. It is therefore time to stop attempting to differentiate between pneumonia type and use the term frailty-associated pneumonia.
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Boere TM, El Alili M, van Buul LW, Hopstaken RM, Verheij TJM, Hertogh CMPM, van Tulder MW, Bosmans JE. Cost-effectiveness and return-on-investment of C-reactive protein point-of-care testing in comparison with usual care to reduce antibiotic prescribing for lower respiratory tract infections in nursing homes: a cluster randomised trial. BMJ Open 2022; 12:e055234. [PMID: 36109036 PMCID: PMC9478864 DOI: 10.1136/bmjopen-2021-055234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES C-reactive protein point-of-care testing (CRP POCT) is a promising diagnostic tool to guide antibiotic prescribing for lower respiratory tract infections (LRTI) in nursing home residents. This study aimed to evaluate cost-effectiveness and return-on-investment (ROI) of CRP POCT compared with usual care for nursing home residents with suspected LRTI from a healthcare perspective. DESIGN Economic evaluation alongside a cluster randomised, controlled trial. SETTING 11 Dutch nursing homes. PARTICIPANTS 241 nursing home residents with a newly suspected LRTI. INTERVENTION Nursing home access to CRP POCT (POCT-guided care) was compared with usual care without CRP POCT (usual care). MAIN OUTCOME MEASURES The primary outcome measure for the cost-effectiveness analysis was antibiotic prescribing at initial consultation, and the secondary outcome was full recovery at 3 weeks. ROI analyses included intervention costs, and benefits related to antibiotic prescribing. Three ROI metrics were calculated: Net Benefits, Benefit-Cost-Ratio and Return-On-Investment. RESULTS In POCT-guided care, total costs were on average €32 higher per patient, the proportion of avoided antibiotic prescribing was higher (0.47 vs 0.18; 0.30, 95% CI 0.17 to 0.42) and the proportion of fully recovered patients statistically non-significantly lower (0.86 vs 0.91; -0.05, 95% CI -0.14 to 0.05) compared with usual care. On average, an avoided antibiotic prescription was associated with an investment of €137 in POCT-guided care compared with usual care. Sensitivity analyses showed that results were relatively robust. Taking the ROI metrics together, the probability of financial return was 0.65. CONCLUSION POCT-guided care effectively reduces antibiotic prescribing compared with usual care without significant effects on recovery rates, but requires an investment. Future studies should take into account potential beneficial effects of POCT-guided care on costs and health outcomes related to antibiotic resistance. TRIAL REGISTRATION NUMBER NL5054.
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Affiliation(s)
- Tjarda M Boere
- Department of Medicine for Older People, Amsterdam Public Health research institute, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Mohamed El Alili
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health research institute, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Rogier M Hopstaken
- Star-SHL Diagnostic Center, Etten-Leur, The Netherlands
- Department of General Practice, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health research institute, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Maurits W van Tulder
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences research institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Kosutova P, Mikolka P. Aspiration syndromes and associated lung injury: incidence, pathophysiology and management. Physiol Res 2021. [DOI: 10.33549//physiolres.934767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aspiration is a common condition affecting healthy or sick patients which could create an acute or chronic inflammatory reaction in the lungs. Aspiration syndromes could be categorized according to a content entering the respiratory system into bacterial aspiration pneumonia with the gastric or oropharyngeal bacteria entering, aspiration chemical pneumonitis with bacteria-freegastric acid aspiration, or aspiration of a foreign body which causes an acute pulmonary emergency. There are differences in the clinical presentation of volume-dependent aspirations (microaspiration and macroaspiration): the higher is the volume of aspiration, the greater is the injury to the patient and more serious are the health consequences (with 70 % mortality rate for hospitalized patients). Aspiration syndromes can affect both the airways and pulmonary parenchyma, leading to acute lung injury, increased hospitalization rate and worse outcomes in critically ill patients. Impaired alveolar-capillary permeability, oedema formation, neutrophilic inflammatory response and pulmonary surfactant inactivation lead to reduced lung compliance and loss of aerated lung tissue and give rise to hypoxemia and respiratory failure. This review discusses the effect of aspiration events on the pulmonary tissue. The main focus is to distinguish the differences between bacterial and chemical pneumonia, their clinical presentation and symptoms, risk factors of developing the changes, possibilities of diagnostics and management as well as prevention of aspirations. Because of a risk of serious lung damage after the aspiration, pathophysiology and processes leading to lung tissue injury are discussed in detail. Data sources represent a systematic literature search using relevant medical subject headings.
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6
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Implementation and Use of Point-of-Care C-Reactive Protein Testing in Nursing Homes. J Am Med Dir Assoc 2021; 23:968-975.e3. [PMID: 34626578 DOI: 10.1016/j.jamda.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study evaluated logistics, process data, and barriers/facilitators for the implementation and use of C-reactive protein point-of-care testing (CRP POCT) for suspected lower respiratory tract infections (LRTIs) in nursing home (NH) residents. DESIGN This process evaluation was performed alongside a cluster randomized, controlled trial (UPCARE study) to evaluate the effect of CRP POCT on antibiotic prescribing for suspected LRTIs in NH residents. SETTING AND PARTICIPANTS Eleven NHs in the Netherlands. METHODS Data sources for process data regarding intervention quality included a questionnaire among NH staff, logs, reports, and CRP POCT-analyzer records. Barriers and facilitators for implementation were assessed in focus group interviews with physicians and nurses from 3 NHs. RESULTS Correct patient selection for CRP POCT and generally continued CRP POCT use indicated good fidelity. The initial training and training of new employees seemed to fit the need, but some POCT-user group sizes had increased over time, which could have impeded frequent use. Users were generally satisfied with CRP POCT and perceived its use feasible and relevant. Facilitators for implementation were initial commitment and active initiation, followed by continued attention and enthusiasm for building routine practice and trust. Short lines of communication between staff, short distance to the POCT-analyzer, 24/7 coverage of staff, and a clear task division facilitated continued attention and routine practice. CONCLUSIONS AND IMPLICATIONS This process evaluation showed sufficient quality of providing CRP POCT in Dutch NHs. We processed findings of intervention quality and implementation knowledge into key recommendations for CRP POCT implementation in this setting. Future research could focus on CRP POCT use in countries with different organization of care in NHs.
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Boere TM, van Buul LW, Hopstaken RM, van Tulder MW, Twisk JWMR, Verheij TJM, Hertogh CMPM. Effect of C reactive protein point-of-care testing on antibiotic prescribing for lower respiratory tract infections in nursing home residents: cluster randomised controlled trial. BMJ 2021; 374:n2198. [PMID: 34548288 PMCID: PMC8453309 DOI: 10.1136/bmj.n2198] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate whether C reactive protein point-of-care testing (CRP POCT) safely reduces antibiotic prescribing for lower respiratory tract infections in nursing home residents. DESIGN Pragmatic, cluster randomised controlled trial. SETTING The UPCARE study included 11 nursing home organisations in the Netherlands. PARTICIPANTS 84 physicians from 11 nursing home organisations included 241 participants with suspected lower respiratory tract infections from September 2018 to the end of March 2020. INTERVENTIONS Nursing homes allocated to the intervention group had access to CRP POCT. The control group provided usual care without CRP POCT for patients with suspected lower respiratory tract infections. MAIN OUTCOME MEASURES The primary outcome measure was antibiotic prescribing at initial consultation. Secondary outcome measures were full recovery at three weeks, changes in antibiotic management and additional diagnostics during follow-up at one week and three weeks, and hospital admission and all cause mortality at any point (initial consultation, one week, or three weeks). RESULTS Antibiotics were prescribed at initial consultation for 84 (53.5%) patients in the intervention group and 65 (82.3%) in the control group. Patients in the intervention group had 4.93 higher odds (95% confidence interval 1.91 to 12.73) of not being prescribed antibiotics at initial consultation compared with the control group, irrespective of treating physician and baseline characteristics. The between group difference in antibiotic prescribing at any point from initial consultation to follow-up was 23.6%. Differences in secondary outcomes between the intervention and control groups were 4.4% in full recovery rates at three weeks (86.4% v 90.8%), 2.2% in all cause mortality rates (3.5% v 1.3%), and 0.7% in hospital admission rates (7.2% v 6.5%). The odds of full recovery at three weeks, and the odds of mortality and hospital admission at any point did not significantly differ between groups. CONCLUSIONS CRP POCT for suspected lower respiratory tract infection safely reduced antibiotic prescribing compared with usual care in nursing home residents. The findings suggest that implementing CRP POCT in nursing homes might contribute to reduced antibiotic use in this setting and help to combat antibiotic resistance. TRIAL REGISTRATION Netherlands Trial Register NL5054.
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Affiliation(s)
- Tjarda M Boere
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Rogier M Hopstaken
- Primary Health Care Center, Hapert en Hoogeloon, Hapert, Netherlands
- Star-shl Diagnostic Centers, Etten-Leur, Netherlands
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Maurits W van Tulder
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jos W M R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Theo J M Verheij
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
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Almirall J, Boixeda R, de la Torre MC, Torres A. Aspiration pneumonia: A renewed perspective and practical approach. Respir Med 2021; 185:106485. [PMID: 34087609 DOI: 10.1016/j.rmed.2021.106485] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 11/27/2022]
Abstract
Aspiration pneumonia (AP) is a sub-type of community-acquired pneumonia (CAP) still poorly recognized especially in the absence of an aspiration event. A further difficulty is the differentiation between AP and aspiration pneumonitis. From a clinical perspective, AP is becoming increasingly relevant as a potential cause of severe and life-threatening respiratory infection among frail and very old patients, particularly among those with CAP requiring inpatient care. Moreover, AP is frequently underdiagnosed and a clear-cut definition of this pathological entity is lacking. There are different factors that increase the risk for aspiration, but other common factors influencing oral colonization such as malnutrition, smoking, poor oral hygiene or dry mouth, are also important in the pathogenesis of AP and should be considered. While there is no doubt in the diagnosis of AP in cases of a recent witnessed aspiration of oropharyngeal or gastric content, we here proposed a definition of AP that also includes silent unobserved aspirations. For this reason, the presence of one or more risk factors of oropharyngeal aspiration is required together with one or more risk factors for oral bacterial colonization. This proposed definition based on expert opinion not only unifies the diagnostic criteria of AP, but also provides the possibility to devise easily applicable strategies to prevent oral colonization.
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Affiliation(s)
- Jordi Almirall
- Intensive Care Unit, Hospital de Mataró, Universitat Autònoma de Barcelona, Consorci Sanitari Del Maresme, Mataró, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - Ramon Boixeda
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Service of Internal Medicine, Hospital de Mataró, Consorci Sanitari Del Maresme, Mataró, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain.
| | - Mari C de la Torre
- Intensive Care Unit, Hospital de Mataró, Universitat Autònoma de Barcelona, Consorci Sanitari Del Maresme, Mataró, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - Antoni Torres
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Universitat de Barcelona, Barcelona, Spain; Service of Pneumology, Institut Clínic Del Torax, Institut D'Investigació Biomédica Agustí Pi I Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain.
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Birchall O, Bennett M, Lawson N, Cotton SM, Vogel AP. The Role of Instrumental Swallowing Assessment in Adults in Residential Aged Care Homes: A National Modified Delphi Survey Examining Beliefs and Practices. Dysphagia 2021; 37:510-522. [PMID: 33835262 DOI: 10.1007/s00455-021-10296-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/25/2021] [Indexed: 12/31/2022]
Abstract
Many adults in residential aged care homes (RACHs) live with oropharyngeal dysphagia (OD) and its physiological, psychosocial, and economic sequalae. Timely, evidence-based assessment of OD can help healthcare teams to create OD management plans that optimize consumer health and minimize healthcare costs. Instrumental swallowing assessment (ISA), specifically flexible endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallowing studies (VFSS), is generally accepted to be an important component of dysphagia assessment and management in older adults. However, its role in RACHs has not been empirically examined. This study aimed to explore the role and use of ISA in adults in RACHs from the perspective of speech-language-pathologists (SLPs) experienced in a RACH setting and/or FEES and VFSS. A three-round electronic Delphi study was conducted to guide 58 SLPs in Australia towards consensus using a combination of multiple-choice questions, statements with five-point Likert scale agreement options, and open-ended questions. Participants' responses were analyzed using descriptive statistics and content analysis after each survey round. Feedback about group responses was provided before subsequent surveys. Consensus was defined as 70% or greater agreement. Participants reached consensus about obstacles and facilitators to the use of ISA in RACHs. Participants agreed that FEES was a valuable tool in RACHs and that a mobile service model may have advantages over standard off-site assessment. SLPs believed that appropriate governance processes, infrastructure and education were necessary to develop a safe, high-quality service. These views support equitable access to ISA across settings, aligning with person-centered care, re-ablement, and care-in-place.
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Affiliation(s)
- Olga Birchall
- Centre for Neurosciences of Speech, The University of Melbourne, Melbourne, Australia.
- Department of Audiology and Speech Pathology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, 3010, Australia.
| | - Michelle Bennett
- School of Allied Health, Australian Catholic University, North Sydney, Sydney, Australia
| | - Nadine Lawson
- Speech Pathology Department, Cabrini Hospital, Malvern, Australia
| | - Susan M Cotton
- The National Centre of Excellence in Youth Mental Health, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Adam P Vogel
- Centre for Neurosciences of Speech, The University of Melbourne, Melbourne, Australia
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- Redenlab, Melbourne, Australia
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10
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Groher ME. Respiratory Disorders. Dysphagia 2021. [DOI: 10.1016/b978-0-323-63648-3.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Kistler CE, Jump RLP, Sloane PD, Zimmerman S. The Winter Respiratory Viral Season During the COVID-19 Pandemic. J Am Med Dir Assoc 2020; 21:1741-1745. [PMID: 33256954 PMCID: PMC7586921 DOI: 10.1016/j.jamda.2020.10.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 10/22/2020] [Accepted: 10/22/2020] [Indexed: 02/07/2023]
Abstract
The winter respiratory virus season always poses challenges for long-term care settings; this winter, severe acute respiratory syndrome coronavirus 2 will compound the usual viral infection challenges. This special article discusses unique considerations that Coronavirus Disease 2019 (COVID-19) brings to the health and well-being of residents and staff in nursing homes and other long-term care settings this winter. Specific topics include preventing the spread of respiratory viruses, promoting immunization, and the diagnosis and treatment of suspected respiratory infection. Policy-relevant issues are discussed, including whether to mandate influenza immunization for staff, the availability and use of personal protective equipment, supporting staff if they become ill, and the distribution of a COVID-19 vaccine when it becomes available. Research is applicable in all of these areas, including regarding the use of emerging electronic decision support tools. If there is a positive side to this year's winter respiratory virus season, it is that staff, residents, family members, and clinicians will be especially vigilant about potential infection.
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Affiliation(s)
- Christine E Kistler
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, NC, USA.
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, OH, USA; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population & Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, USA; Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, NC, USA
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Boere TM, van Buul LW, Hopstaken RM, Veenhuizen RB, van Tulder MW, Cals JWL, Verheij TJM, Hertogh CMPM. Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial. BMC Health Serv Res 2020; 20:149. [PMID: 32103747 PMCID: PMC7045632 DOI: 10.1186/s12913-020-5006-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/17/2020] [Indexed: 11/15/2022] Open
Abstract
Background Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting. Methods/design A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no). Discussion This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results. Trial registration Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.
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Affiliation(s)
- Tjarda M Boere
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.
| | | | - Ruth B Veenhuizen
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | | | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Theo J M Verheij
- National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands.,Department of General Practice, Julius Centrum, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.,National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands
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13
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Murray A, Mulkerrin S, O’Keeffe ST. The perils of 'risk feeding'. Age Ageing 2019; 48:478-481. [PMID: 30939597 DOI: 10.1093/ageing/afz027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 03/08/2019] [Indexed: 11/13/2022] Open
Abstract
'Risk feeding' policies, for when people continue to eat and drink despite a perceived risk of choking or aspiration have become common in recent years. We argue that 'feeding' is demeaning language if referring to a person who is eating and drinking rather than to a healthcare technique and that 'risk-anything' is not how decisions are reached. It is true that patients with dysphagia are often unnecessarily designated nil-by-mouth (NBM), especially after a decision has been made that tube feeding is not indicated or is unwanted. However, risk-feeding policies may perpetuate common misperceptions that there is a straightforward relationship between aspiration and pneumonia and that interventions like NBM or tube feeding will reduce the risk of pneumonia. Such policies may reduce the potential for individualised and flexible decision making: many people's swallowing abilities and preferences fluctuate, sometimes from hour to hour, and staff need to have, and be encouraged to use, common sense, flexibility and judgement in these circumstances. There is also the potential for delays in providing food, fluid and medications if meetings must be held and risk-feeding paperwork completed and signed by someone with the necessary seniority and confidence. Further debate and discussion is required before risk-feeding policies become an established standard of care.
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Affiliation(s)
- Aoife Murray
- Department of Geriatric Medicine, Galway University Hospitals, Galway, Ireland
| | - Siofra Mulkerrin
- Department of Speech and Language Therapy, Addenbrooke’s Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, UK
| | - Shaun T O’Keeffe
- Department of Geriatric Medicine, Galway University Hospitals, Galway, Ireland
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14
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Nursing Home-Associated Pneumonia, Part I: Diagnosis. J Am Med Dir Assoc 2019; 21:308-314. [PMID: 31178286 DOI: 10.1016/j.jamda.2019.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 04/21/2019] [Indexed: 11/20/2022]
Abstract
Pneumonia is 1 of the 3 most common infections identified in nursing home residents and is associated with the highest mortality of any infection in this setting. In regard to pneumonia in the nursing home setting, practitioners are focused primarily on identifying residents with this infection and choosing a treatment regimen. In this article, the diagnosis of this infection is addressed. Based on published studies and clinical experience, "bedside criteria" for the diagnosis of nursing home-associated pneumonia (NHAP) are proposed that are based primarily on objective respiratory signs and symptoms that can be readily identified by staff. It is also stressed that factors predisposing to aspiration should be identified because there is a risk for aspiration pneumonitis. A previously published decision tool to distinguish between aspiration pneumonia and aspiration pneumonitis is discussed. Because providers are often not present when there is a change in status of a resident, nursing staff are crucial to the diagnosis of NHAP. However, there is variability in staff experience and the ability to obtain and communicate clinical findings to assist providers in making decisions about diagnosis. To deal with this issue, templates have been developed to help staff collect the appropriate information before contacting the provider. The most important diagnostic test in a resident with suspected pneumonia is a chest radiograph. However, studies done more than a decade ago demonstrated considerable variability in radiologists' interpretation of chest radiographs of residents performed in the nursing home. Radiologic techniques have improved considerably with utilization of digital technology, but there have been no recent studies to determine if interpretation of these radiographs is more consistent. An alternative to radiographs is lung ultrasonography, which has been found to be more accurate than chest radiographs in identifying pneumonia in adults; however, this method has not been studied in the nursing home setting. Host biomarkers such as serum C-reactive protein and procalcitonin levels have been studied in adults with pneumonia to distinguish between bacterial and nonbacterial infection, but there has been limited study in NHAP and the findings are conflicting. Lastly, it is stressed that the provider should carefully document the clinical findings and testing that result in a diagnosis of pneumonia to enhance surveillance for infection as well as antimicrobial stewardship activities.
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15
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Lewis C, Greiner LH, Brown DR. Setback distances for unconventional oil and gas development: Delphi study results. PLoS One 2018; 13:e0202462. [PMID: 30114206 PMCID: PMC6095590 DOI: 10.1371/journal.pone.0202462] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/20/2018] [Indexed: 11/18/2022] Open
Abstract
Emerging evidence indicates that proximity to unconventional oil and gas development (UOGD) is associated with health outcomes. There is intense debate about "How close is too close?" for maintaining public health and safety. The goal of this Delphi study was to elicit expert consensus on appropriate setback distances for UOGD from human activity. Three rounds were used to identify and seek consensus on recommended setback distances. The 18 panelists were health care providers, public health practitioners, environmental advocates, and researchers/scientists. Consensus was defined as agreement of ≥70% of panelists. Content analysis of responses to Round 1 questions revealed four categories: recommend setback distances; do not recommend setback distances; recommend additional setback distances for vulnerable populations; do not recommend additional setback distances for vulnerable populations. In Round 2, panelists indicated their level of agreement with the statements in each category using a five-point Likert scale. Based on emerging consensus, statements within each category were collapsed into seven statements for Round 3: recommend set back distances of <¼ mile; ¼-½ mile; 1-1 ¼ mile; and ≥ 2 mile; not feasible to recommend setback distances; recommend additional setbacks for vulnerable groups; not feasible to recommend additional setbacks for vulnerable groups. The panel reached consensus that setbacks of < ¼ mile should not be recommended and additional setbacks for vulnerable populations should be recommended. The panel did not reach consensus on recommendations for setbacks between ¼ and 2 miles. The results suggest that if setbacks are used the distances should be greater than ¼ of a mile from human activity, and that additional setbacks should be used for settings where vulnerable groups are found, including schools, daycare centers, and hospitals. The lack of consensus on setback distances between 1/4 and 2 miles reflects the limited health and exposure studies and need to better define exposures and track health.
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Affiliation(s)
- Celia Lewis
- Southwest Pennsylvania Environmental Health Project, New Haven, Connecticut, United States of America
| | - Lydia H. Greiner
- Southwest Pennsylvania Environmental Health Project, McMurray, Pennsylvania, United States of America
| | - David R. Brown
- Southwest Pennsylvania Environmental Health Project, New Haven, Connecticut, United States of America
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16
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Jump RLP, Crnich CJ, Mody L, Bradley SF, Nicolle LE, Yoshikawa TT. Infectious Diseases in Older Adults of Long-Term Care Facilities: Update on Approach to Diagnosis and Management. J Am Geriatr Soc 2018; 66:789-803. [PMID: 29667186 PMCID: PMC5909836 DOI: 10.1111/jgs.15248] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The diagnosis, treatment, and prevention of infectious diseases in older adults in long-term care facilities (LTCFs), particularly nursing facilities, remains a challenge for all health providers who care for this population. This review provides updated information on the currently most important challenges of infectious diseases in LTCFs. With the increasing prescribing of antibiotics in older adults, particularly in LTCFs, the topic of antibiotic stewardship is presented in this review. Following this discussion, salient points on clinical relevance, clinical presentation, diagnostic approach, therapy, and prevention are discussed for skin and soft tissue infections, infectious diarrhea (Clostridium difficile and norovirus infections), bacterial pneumonia, and urinary tract infection, as well as some of the newer approaches to preventive interventions in the LTCF setting.
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Affiliation(s)
- Robin L P Jump
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
- Specialty Care Center of Innovation, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
- Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Christopher J Crnich
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- William S. Middleton Veterans Affairs Medical Center, Madison, Wisconsin
- University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Lona Mody
- Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Division of Geriatric and Palliative Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Suzanne F Bradley
- Division of Infectious Diseases, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Lindsay E Nicolle
- Department of Internal Medicine, Health Sciences Centre, University of Manitoba, Winnepeg, Manitoba, Canada
- Department of Medical Microbiology, Health Sciences Centre, University of Manitoba, Winnepeg, Manitoba, Canada
| | - Thomas T Yoshikawa
- Geriatric and Extended Care Service, Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
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17
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Duarte M, Bouça-Machado R, Domingos J, Godinho C, Ferreira JJ. Feasibility of using risk prompts to prevent falls, dehydration and pulmonary aspiration in nursing homes: a clinical study protocol. Pilot Feasibility Stud 2018; 4:39. [PMID: 29416872 PMCID: PMC5785817 DOI: 10.1186/s40814-018-0236-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 01/16/2018] [Indexed: 02/07/2023] Open
Abstract
Background Evidence has shown a relationship between dehydration, falls, and pulmonary aspiration among older adults in nursing homes, all of which contribute to loss of independence and quality of life. It is believed that improving communication among healthcare professionals in nursing homes (physicians, nurses, rehabilitation team, psychologist, social workers, dieticians and medical assistants) decreases the number of adverse events in institutionalized patients. This study will evaluate the feasibility of using a set of written signs, designed to caution against the risk of falls, dehydration, and pulmonary aspiration, and will enable the proposal of tailored interventions to manage these events in nursing homes. Methods/Design All patients from Campus Neurológico Sénior (CNS) nursing home, at risk of falls and/ordysphagia and/or dehydration will be invited to participate in the study. Patients will undertake a screeningrisk assessment and the corresponding risk prompts will be attributed. Study duration will be a minimum ofthree months per participant, including daily record of falls, dehydration and pulmonary aspiration eventsand monthly interview assessments, conducted by a member of the research team. Data of the events that occur will be compared with historical data extracted retrospectively from medical and nursing charts. This study has been approved by the Ethics Committee of the Medical Academic Center of Lisbon, Faculty of Medicine, University of Lisbon (Ref. 176/15). All participants will give their written informed consent before entering the study. Discussion This study is unique in evaluating the feasibility of a communication system in preventing the three major risks in nursing home. Thoughtful selection and display of proper risk prompts in nursing homes could be an essential step along a path toward efficient communication of risks among healthcare teams. We expect that the displays will be easily applicable given their simplicity, low complexity, and minimal physical requirements. Trial registration NCT03123601. March 7, 2017. Retrospectively registered.
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Affiliation(s)
- Márcia Duarte
- CNS-Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Raquel Bouça-Machado
- CNS-Campus Neurológico Sénior, Torres Vedras, Portugal.,2Instituto de Medicina Molecular, Lisbon, Portugal
| | | | - Catarina Godinho
- CNS-Campus Neurológico Sénior, Torres Vedras, Portugal.,2Instituto de Medicina Molecular, Lisbon, Portugal.,3Centro de Investigação Interdisciplinar Egas Moniz, Escola Superior de Saúde Egas Moniz, Monte de Caparica, Portugal
| | - Joaquim J Ferreira
- CNS-Campus Neurológico Sénior, Torres Vedras, Portugal.,2Instituto de Medicina Molecular, Lisbon, Portugal.,4Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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18
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McClester Brown M, Sloane PD, Kistler CE, Reed D, Ward K, Weber D, Zimmerman S. Evaluation and Management of the Nursing Home Resident With Respiratory Symptoms and an Equivocal Chest X-Ray Report. J Am Med Dir Assoc 2016; 17:1164.e1-1164.e5. [PMID: 27815108 DOI: 10.1016/j.jamda.2016.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 09/18/2016] [Accepted: 09/19/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Pneumonia is a leading cause of morbidity and mortality in nursing home (NH) residents. Chest x-ray evidence is considered a key diagnostic criterion for pneumonia by the Infectious Disease Society of America (IDSA) diagnostic guidelines, the modified McGeer diagnostic criteria, and the Loeb criteria for initiating antibiotics; however, x-ray interpretation is often equivocal. We conducted chart audits of patients in NHs who had chest x-rays for new respiratory symptoms to determine the degree of ambiguity in the radiology reports and their relationship to antibiotic prescription decisions. DESIGN Cross-sectional study. SETTING Thirty-one NHs in North Carolina. PARTICIPANTS Two hundred twenty-six NH residents who had a chest x-ray. METHODS Medical charts were abstracted to record (1) the patient's clinical presentation when a chest x-ray was ordered, (2) the verbatim report of the chest x-ray, and (3) the patient's course during the subsequent 7 days. To standardize the radiologist reports, a seven-category coding system was developed, which was further aggregated into three groups based on the radiologist's description of the likelihood of pneumonia. RESULTS Of the 226 chest x-rays, 118 (52%) identified a very low likelihood of pneumonia, 67 (30%) indicated that pneumonia was present or highly likely, and the remaining 41 (18%) used a variety of terms to describe uncertainty regarding the presence of pneumonia. NH medical providers tended to treat ambiguous chest x-ray reports similarly to positive x-ray reports, prescribing antibiotic therapy to 71% of patients with ambiguous reports and 78% of positive reports. Also notable is that 40 (34%) of the 118 patients with a very low likelihood of pneumonia based on chest x-ray results were prescribed antibiotics, the majority of whom failed to meet criteria for a clinical diagnosis of pneumonia or chronic obstructive pulmonary disease exacerbation. CONCLUSION The moderate rate of ambiguous x-ray interpretations in NH residents is likely a combination of the poor quality of portable x-rays, a high prevalence of chronic lung conditions, and conservative (ie, cautious) decision making by radiologists whose interpretation is based on little clinical information and a suboptimal quality film. As a result, data suggest that chest x-rays obtained in NHs may unnecessarily encourage antibiotic prescribing because a majority of readings are ambiguous or show a low likelihood of pneumonia, yet more than half of the patients are still treated. From an antibiotic stewardship standpoint, the apparent solution is to more closely rely on clinical signs and symptoms for diagnosis of pneumonia and to place less emphasis on the role of the chest x-ray given the high number of unclear readings.
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Affiliation(s)
- Mallory McClester Brown
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Philip D Sloane
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christine E Kistler
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David Reed
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kimberly Ward
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David Weber
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Medicine and Pediatrics, Division of Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC
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