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Basso I, Gonella S, Bassi E, Caristia S, Campagna S, Dal Molin A. Quality improvement interventions to prevent the use of hospital services among nursing home residents: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e074684. [PMID: 37758680 PMCID: PMC10537830 DOI: 10.1136/bmjopen-2023-074684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION Quality improvement interventions are a promising strategy for reducing hospital services use among nursing home residents. However, evidence for their effectiveness is limited. It is unclear which characteristics of the quality improvement intervention and activities planned to facilitate implementation may promote fidelity to organisational and system changes. This systematic review and meta-analysis will assess the effectiveness of quality improvement interventions and implementation strategies aimed at reducing hospital services use among nursing home residents. METHODS AND ANALYSIS The MEDLINE, CINAHL, Cochrane Library, Embase and Web of Science databases will be comprehensively searched in September 2023. The eligible studies should focus on the implementation of a quality improvement intervention defined as the systematic, continuous approach that designs, tests and implements changes using real-time measurement to reduce hospitalisations or emergency department visits among long-stay nursing home residents. Quality improvement details and implementation strategies will be deductively categorised into effective practice and organisation of care taxonomy domains for delivery arrangements and implementation strategies. Quality and bias assessments will be completed using the Quality Improvement Minimum Quality Criteria Set and the Joanna Briggs Institute Critical Appraisal Tools.The results will be pooled in a meta-analysis, by combining the natural logarithms of the rate ratios across the studies or by calculating the rate ratio using the generic inverse-variance method. Heterogeneity will be assessed using the I2 or H2 statistics if the number of included studies will be less than 10. Raw data will be requested from the authors, as required. ETHICS AND DISSEMINATION Ethical approval is not required. The results will be published in a peer-review journal and presented at (inter)national conferences. PROSPERO REGISTRATION NUMBER CRD42022364195.
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Affiliation(s)
- Ines Basso
- Department of Medicina Traslazionale, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Vercelli, Italy
| | - Silvia Gonella
- Direction of Health Professions, Azienda Ospedaliero Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy
| | - Erika Bassi
- Department of Medicina Traslazionale, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Vercelli, Italy
| | - Silvia Caristia
- Department of Medicina Traslazionale, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Vercelli, Italy
| | - Sara Campagna
- Department of Public Health and Pediatrics, Università degli Studi di Torino, Torino, Italy
| | - Alberto Dal Molin
- Department of Medicina Traslazionale, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Vercelli, Italy
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Colburn JL, Scerpella DL, Chapin M, Walker KA, Dy SM, Saylor MA, Sharma N, Rebala S, Anderson RE, McGuire M, Hussain N, Rawlinson C, Cotter V, Cockey K, Roth DL, Nicholson KLC, Giovannetti ER, Sancho MB, Echavarria D, Boyd CM, Wolff JL, Smith KM. SHARING Choices: Lessons Learned from a Primary-Care Focused Advance Care Planning Intervention. J Pain Symptom Manage 2023; 66:e255-e264. [PMID: 37100306 DOI: 10.1016/j.jpainsymman.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/24/2023] [Accepted: 04/08/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Few advance care planning (ACP) interventions have been scaled in primary care. PROBLEM Best practices for delivering ACP at scale in primary care do not exist and prior efforts have excluded older adults with Alzheimer's Disease and Related Dementias (ADRD). INTERVENTION SHARING Choices (NCT#04819191) is a multicomponent cluster-randomized pragmatic trial conducted at 55 primary care practices from two care delivery systems in the Mid-Atlantic region of the U.S. We describe the process of implementing SHARING Choices within 19 practices randomized to the intervention, summarize fidelity to planned implementation, and discuss lessons learned. OUTCOMES Embedding SHARING Choices involved engagement with organizational and clinic-level partners. Of 23,220 candidate patients, 17,931 outreach attempts by phone (77.9%) and the patient portal (22.1%) were made by ACP facilitators and 1215 conversations occurred. Most conversations (94.8%) were less than 45 minutes duration. Just 13.1% of ACP conversations included family. Patients with ADRD comprised a small proportion of patients who engaged in ACP. Implementation adaptations included transitioning to remote modalities, aligning ACP outreach with the Medicare Annual Wellness Visit, accommodating primary care practice flexibility. LESSONS LEARNED Study findings reinforce the value of adaptable study design; co-designing workflow adaptations with practice staff; adapting implementation processes to fit the unique needs of two health systems; and modifying efforts to meet health system goals and priorities.
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Affiliation(s)
- Jessica L Colburn
- Division of Geriatric Medicine & Gerontology (JLC, CMB), Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Daniel L Scerpella
- Department of Health Policy and Management (DLS, DE, JLW), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Margo Chapin
- Johns Hopkins University (MC), Baltimore, MD, USA
| | - Kathryn A Walker
- Palliative Care (KAW, SMD, KC), MedStar Health, Columbia, MD, USA
| | - Sydney M Dy
- Palliative Care (KAW, SMD, KC), MedStar Health, Columbia, MD, USA
| | | | | | - Sri Rebala
- MedStar Health (NS, SR), Columbia, MD, USA
| | - Ryan E Anderson
- Clinical Care Transformation (REA, ERQ), MedStar Health, Columbia, MD, USA
| | - Maura McGuire
- Johns Hopkins Community Physicians (MM), Baltimore, MD, USA
| | - Naaz Hussain
- Johns Hopkins Community Physicians (NH, CR), Frederick, MD, USA
| | | | - Valerie Cotter
- Johns Hopkins School of Nursing (MAS, VC), Baltimore, MD, USA
| | - Kimberly Cockey
- Palliative Care (KAW, SMD, KC), MedStar Health, Columbia, MD, USA
| | - David L Roth
- Division of Geriatric Medicine and Gerontology (DLR), Center on Aging and Health, Baltimore, MD, USA
| | | | | | - Marcella B Sancho
- JHCP Mt. Washington Campus - Marbury Building (MBS), Baltimore, MD, USA
| | - Diane Echavarria
- Department of Health Policy and Management (DLS, DE, JLW), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine & Gerontology (JLC, CMB), Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management (DLS, DE, JLW), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kelly M Smith
- MedStar Health Institute for Quality and Safety (KMS), MedStar Health, Columbia, MD, USA
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Smith NLH, Sudore RL, Myers AL, Hammes BJ, Hickman SE. Reasons for Discordance Between Life-Sustaining Treatment Preferences and Medical Orders in Nursing Facilities Without POLST. Am J Hosp Palliat Care 2023; 40:837-843. [PMID: 36154692 PMCID: PMC10321076 DOI: 10.1177/10499091221127996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Life-sustaining treatment (LST) orders are important communication tools used to ensure preference-concordant care at the end of life. Recent studies reveal concerning rates of discordance between current preferences and documented LST orders, especially in nursing facilities without POLST. Reasons for discordance in facilities using POLST have been explored, however the majority of nursing facilities in the United States do not yet use the POLST form. DESIGN Qualitative descriptive study using constant comparative analysis. SETTING Nursing facilities in Indiana (n = 6) not using POLST. PARTICIPANTS Residents (n = 15) and surrogate decision-makers of residents without decisional capacity (n = 15) with discordance between current preferences and documented LST orders. MEASUREMENTS Do not resuscitate, do not hospitalize (DNH), and do not intubate (DNI) orders were extracted from medical charts. Current preferences were elicited using the Respecting Choices Advanced Steps model. A semi-structured interview guide was used to explore reasons for discordance between current preferences and LST orders. RESULTS Reasons for discordance included: (1) inadequate information about the range of available LST options, what each involves, and how to formally communicate preferences; (2) no previous discussion with facility staff; (3) no documentation of previously expressed preferences; and (4) family involvement. CONCLUSION Reasons for discordance between expressed preferences and LST orders suggest that in facilities without a uniform and systematic LST order documentation strategy like POLST, these conversations may not occur and/or be documented. Staff should be aware that residents and surrogates may have preferences about LSTs that require strategic solicitation and documentation.
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Affiliation(s)
- Nicholette L. Heim Smith
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Anne L. Myers
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
| | - Bernard J. Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, WI, USA
| | - Susan E. Hickman
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Center for Aging Research, Regenstrief Institute Inc., Indianapolis, IN, USA
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
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Hickman SE, Lum HD, Walling AM, Savoy A, Sudore RL. The care planning umbrella: The evolution of advance care planning. J Am Geriatr Soc 2023; 71:2350-2356. [PMID: 36840690 PMCID: PMC10958534 DOI: 10.1111/jgs.18287] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Susan E. Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Hillary D. Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Center, Colorado, Aurora, USA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, School of Medicine, University of California Los Angeles, California, Los Angeles, USA
- VA Greater Los Angeles Health System, Los Angeles, California, USA
| | - April Savoy
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco, San Francisco, California, USA
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Hendricksen M, Loizeau AJ, Habtemariam DA, Anderson RA, Hanson LC, D'Agata EM, Mitchell SL. Provider adherence to training components from the Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD) intervention. Contemp Clin Trials Commun 2022; 27:100913. [PMID: 35369403 PMCID: PMC8965910 DOI: 10.1016/j.conctc.2022.100913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 02/28/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background The Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD) was a cluster randomized clinical trial evaluating a multicomponent program to improve infection management among residents with advanced dementia. This report examines facility and provider characteristics associated with greater adherence to training components of the TRAIN-AD intervention. Methods Logistic regression was used to identify facility and provider characteristics associated with: 1. Training seminar attendance, 2. Online course completion, and 3. Overall adherence, defined as participation in neither seminar nor course, either seminar or course, or both seminar and course. Results Among 380 participating providers (nurses, N = 298; prescribing providers, N = 82) almost all (93%) participated in at least one training activity. Being a nurse was associated with higher likelihood of any seminar attendance (adjusted odds ratio (AOR) 5.37; 95% confidence interval (CI), 2.80–10.90). Providers who were in facilities when implementation begun (AOR, 3.01; 95% CI, 1.34–6.78) and in facilities with better quality ratings (AOR, 2.70; 95% CI, 1.59–4.57) were more likely to complete the online course. Prevalent participation (AOR, 2.01; 95% CI, 1.02–3.96) and higher facility quality (AOR, 2.44; 95% CI, 1.27–4.66) were also significantly associated with greater adherence to either seminar or online course. Conclusion TRAIN-AD demonstrates feasibility in achieving high participation among nursing home providers in intervention training activities. Findings also suggest opportunities to maximize adherence, such as enhancing training efforts in lower quality facilities and targeting of providers who join the facility after implementation start-up. High levels of participation was due in part to flexibility of training options and engagement, making it easily accessible. Stakeholder engagement on priority issues and the start-up period on site were important to get buy-in from participants. Lessons learned provide insight into improving adherence for interventions, particularly for NHs with lower resources.
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Affiliation(s)
- Meghan Hendricksen
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, United States
- Corresponding author. Hebrew SeniorLife Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, United States.
| | - Andrea J. Loizeau
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, United States
| | - Daniel A. Habtemariam
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, United States
| | - Ruth A. Anderson
- School of Nursing, University of North Carolina, Chapel Hill, NC, United States
| | - Laura C. Hanson
- Division of Geriatric Medicine, Palliative Care Program, University of North Carolina Chapel Hill, NC, United States
| | - Erika M.C. D'Agata
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - Susan L. Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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McCreedy EM, Yang X, Mitchell SL, Gutman R, Teno J, Loomer L, Moyo P, Volandes A, Gozalo PL, Belanger E, Ogarek J, Mor V. Effect of advance care planning video on do-not-hospitalize orders for nursing home residents with advanced illness. BMC Geriatr 2022; 22:298. [PMID: 35392827 PMCID: PMC8991654 DOI: 10.1186/s12877-022-02970-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of the study is to evaluate the effect of an Advance Care Planning (ACP) Video Program on documented Do-Not-Hospitalize (DNH) orders among nursing home (NH) residents with advanced illness. METHODS Secondary analysis on a subset of NHs enrolled in a cluster-randomized controlled trial (41 NHs in treatment arm implemented the ACP Video Program: 69 NHs in control arm employed usual ACP practices). Participants included long (> 100 days) and short (≤ 100 days) stay residents with advanced illness (advanced dementia or cardiopulmonary disease (chronic obstructive pulmonary disease or congestive heart failure)) in NHs from March 1, 2016 to May 31, 2018 without a documented Do-Not-Hospitalize (DNH) order at baseline. Logistic regression with covariate adjustments was used to estimate the impact of the resident being in a treatment versus control NH on: the proportion of residents with new DNH orders during follow-up; and the proportion of residents with any hospitalization during follow-up. Clustering at the facility-level was addressed using hierarchical models. RESULTS The cohort included 6,117 residents with advanced illness (mean age (SD) = 82.8 (8.4) years, 65% female). Among long-stay residents (n = 3,902), 9.3% (SE, 2.2; 95% CI 5.0-13.6) and 4.2% (SE, 1.1; 95% CI 2.1-6.3) acquired a new DNH order in the treatment and control arms, respectively (average marginal effect, (AME) 5.0; SE, 2.4; 95% CI, 0.3-9.8). Among short-stay residents with advanced illness (n = 2,215), 8.0% (SE, 1.6; 95% CI 4.6-11.3) and 3.5% (SE 1.0; 95% CI 1.5-5.5) acquired a new DNH order in the treatment and control arms, respectively (AME 4.4; SE, 2.0; 95% CI, 0.5-8.3). Proportion of residents with any hospitalizations did not differ between arms in either cohort. CONCLUSIONS Compared to usual care, an ACP Video Program intervention increased documented DNH orders among NH residents with advanced disease but did not significantly reduce hospitalizations. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02612688 .
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Affiliation(s)
- Ellen M McCreedy
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA. .,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.
| | - Xiaofei Yang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St, Boston, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Joan Teno
- Oregon Health Sciences University School of Medicine, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business and Economics, University of Minnesota Duluth, 1518 Kirby Dr, Duluth, MN, 55806, USA
| | - Patience Moyo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Angelo Volandes
- Section of General Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Emmanuelle Belanger
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Jessica Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
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Levy C, Zimmerman S, Mor V, Gifford D, Greenberg SA, Klinger JH, Lieblich C, Linnebur S, McAllister A, Nazir A, Pace D, Stone R, Resnick B, Sloane PD, Ouslander J, Gaugler JE. Pragmatic Trials in Long-Term Care: Implementation and Dissemination Challenges and Opportunities. J Am Geriatr Soc 2022; 70:709-717. [PMID: 35195281 PMCID: PMC8944211 DOI: 10.1111/jgs.17698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 11/28/2022]
Abstract
Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce findings that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants identified 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) stakeholder engagement, (2) diversity and inclusion, (3) organizational strain and readiness, and (4) learn from adaptations. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions.
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Affiliation(s)
- Cari Levy
- Department of Veterans Affairs, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA,University of Colorado, Aurora, CO, USA,Address correspondence to Cari Levy, MD, PhD, Division of Health Care Policy and Research, University of Colorado at Denver HSC, 13611 E Colfax Ave, Aurora, CO 80045, USA. (C. Levy)
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vincent Mor
- Center of Innovation in Long-term Services and Supports, Providence VA Medical Center, Providence, RI, USA,Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David Gifford
- Center for Health Policy Evaluation, American Health Care Association, Washington, DC, USA,Center for Quality and Innovation, School of Public Health, Brown University, Providence, RI, USA
| | | | | | | | | | | | - Arif Nazir
- Signature HealthCARE, Louisville, KY, USA
| | | | | | - Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Philip D. Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph Ouslander
- Department of Integrated Medical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Joseph E. Gaugler
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Berry SD, Goldfeld KS, McConeghy K, Gifford D, Davidson HE, Han L, Syme M, Gandhi A, Mitchell SL, Harrison J, Recker A, Johnson KS, Gravenstein S, Mor V. Evaluating the Findings of the IMPACT-C Randomized Clinical Trial to Improve COVID-19 Vaccine Coverage in Skilled Nursing Facilities. JAMA Intern Med 2022; 182:324-331. [PMID: 35099523 PMCID: PMC8804975 DOI: 10.1001/jamainternmed.2021.8067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Identifying successful strategies to increase COVID-19 vaccination among skilled nursing facility (SNF) residents and staff is integral to preventing future outbreaks in a continually overwhelmed system. OBJECTIVE To determine whether a multicomponent vaccine campaign would increase vaccine rates among SNF residents and staff. DESIGN, SETTING, AND PARTICIPANTS This was a cluster randomized trial with a rapid timeline (December 2020-March 2021) coinciding with the Pharmacy Partnership Program (PPP). It included 133 SNFs in 4 health care systems across 16 states: 63 and 70 facilities in the intervention and control arms, respectively, and participants included 7496 long-stay residents (>100 days) and 17 963 staff. INTERVENTIONS Multicomponent interventions were introduced at the facility level that included: (1) educational material and electronic messaging for staff; (2) town hall meetings with frontline staff (nurses, nurse aides, dietary, housekeeping); (3) messaging from community leaders; (4) gifts (eg, T-shirts) with socially concerned messaging; (5) use of a specialist to facilitate consent with residents' proxies; and (6) funds for additional COVID-19 testing of staff/residents. MAIN OUTCOMES AND MEASURES The primary outcomes of this study were the proportion of residents (from electronic medical records) and staff (from facility logs) who received a COVID-19 vaccine (any), examined as 2 separate outcomes. Mixed-effects generalized linear models with a binomial distribution were used to compare outcomes between arms, using intent-to-treat approach. Race was examined as an effect modifier in the resident outcome model. RESULTS Most facilities were for-profit (95; 71.4%), and 1973 (26.3%) of residents were Black. Among residents, 82.5% (95% CI, 81.2%-83.7%) were vaccinated in the intervention arm, compared with 79.8% (95% CI, 78.5%-81.0%) in the usual care arm (marginal difference 0.8%; 95% CI, -1.9% to 3.7%). Among staff, 49.5% (95% CI, 48.4%-50.6%) were vaccinated in the intervention arm, compared with 47.9% (95% CI, 46.9%-48.9%) in usual care arm (marginal difference: -0.4%; 95% CI, -4.2% to 3.1%). There was no association of race with the outcome among residents. CONCLUSIONS AND RELEVANCE A multicomponent vaccine campaign did not have a significant effect on vaccination rates among SNF residents or staff. Among residents, vaccination rates were high. However, half the staff remained unvaccinated despite these efforts. Vaccination campaigns to target SNF staff will likely need to use additional approaches. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04732819.
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Affiliation(s)
- Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Keith S Goldfeld
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Kevin McConeghy
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island.,Providence Veteran's Administration Medical Center, Providence, Rhode Island
| | - David Gifford
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, DC
| | | | - Lisa Han
- Insight Therapeutics, Norfolk, Virginia
| | - Maggie Syme
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Ashvin Gandhi
- University of California, Los Angeles Anderson School of Management, Los Angeles
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jill Harrison
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Amy Recker
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Kimberly S Johnson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Stefan Gravenstein
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island.,Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Vincent Mor
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island.,Providence Veteran's Administration Medical Center, Providence, Rhode Island
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Levy C, Zimmerman S, Mor V, Gifford D, Greenberg SA, Klinger JH, Lieblich C, Linnebur S, McAllister A, Nazir A, Pace D, Stone R, Resnick B, Sloane PD, Ouslander J, Gaugler JE. Pragmatic trials in long-term care: Challenges, opportunities, recommendations. Geriatr Nurs 2022; 44:282-287. [DOI: 10.1016/j.gerinurse.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pragmatic Trials in Long-Term Care: Challenges, Opportunities, Recommendations. J Am Med Dir Assoc 2021; 23:339-344. [PMID: 34919838 DOI: 10.1016/j.jamda.2021.11.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/14/2021] [Accepted: 11/18/2021] [Indexed: 11/24/2022]
Abstract
Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce data that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants recommended 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) engage stakeholders, (2) ensure diversity and inclusion, (3) assess organizational strain and readiness, and (4) learn from adaptations. Specifically related to implementation, participants provided 2 recommendations: (1) integrate interventions into existing workflows and (2) maintain agility and responsiveness. Finally, participants had 3 recommendations specific to dissemination: (1) package the message for the audience, (2) engage diverse audiences, and (3) apply dissemination and diffusion tools. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions.
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Zhao Y, Liao L, Feng H, Chen H, Ning H. Enablers and barriers to implementing care quality improvement program in nursing homes in China. BMC Geriatr 2021; 21:532. [PMID: 34620127 PMCID: PMC8496049 DOI: 10.1186/s12877-021-02488-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 09/16/2021] [Indexed: 11/10/2022] Open
Abstract
Objective To explore the perspectives of key stakeholders on necessary factors to implement care quality improvement program. Methods We conducted qualitative descriptive research in eight nursing homes in four major prefecture-level cities of Changsha, Xiangtan, Zhuzhou, and Yueyang. Data of 50 clinical nurses and 64 nurse assistants were included and analyzed. Ethical approval was given by the medical ethics committee of Chinese Clinical Trial Registry (No. ChiCTR-IOC-17013109, https://www.chictr.org.cn/index.aspx). One-to-one interviews were used with the nursing managers, and separate focus group discussions were used with the clinical nurses and nurse assistants. All of the interviews were audio recorded and later transcribed verbatim. In addition, the first author documented the responses of every participant in the field notes during the interviews and focus groups. Results The participants’ perspectives were characterized by two main themes: (1) enablers, with four subthemes of “organizational support”, “the evidence-based practice ability”, “proactivity”, “nursing supervision and feedback;” and (2) barriers, with five sub-themes of “low educational background”, “the limitations of self-role orientation”, “resistance to change”, “lack of job motivation”, and “organizational constraints”. Conclusion These findings recognize factors at the organizational level, staff level and societal level that are necessary to implement effective mentoring. The results of this study can provide reference for nursing home in improving nursing management quality, formulating, implementing and revising training policies.
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Affiliation(s)
- Yinan Zhao
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Lulu Liao
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Hui Feng
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China. .,Xiangya-Oceanwide Health Management Research Institute, Central South University, Changsha, China. .,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, China.
| | - Huijing Chen
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Hongting Ning
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
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Dir AL, Watson DP, Zhiss M, Taylor L, Bray BC, McGuire A. Barriers impacting the POINT pragmatic trial: the unavoidable overlap between research and intervention procedures in "real-world" research. Trials 2021; 22:114. [PMID: 33541402 PMCID: PMC7859893 DOI: 10.1186/s13063-021-05065-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 01/20/2021] [Indexed: 12/03/2022] Open
Abstract
Background This manuscript provides a research update to the ongoing pragmatic trial of Project POINT (Planned Outreach, Intervention, Naloxone, and Treatment), an emergency department-based peer recovery coaching intervention for linking patients with opioid use disorder to evidence-based treatment. The research team has encountered a number of challenges related to the “real-world” study setting since the trial began. Using an implementation science lens, we sought to identify and describe barriers impacting both the intervention and research protocols of the POINT study, which are often intertwined in pragmatic trials due to the focus on external validity. Method Qualitative data were collected from 3 peer recovery coaches, 2 peer recovery coach supervisors, and 3 members of the research team. Questions and deductive qualitative analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Results Nine unique barriers were noted, with 5 of these barriers impacting intervention and research protocol implementation simultaneously. These simultaneous barriers were timing of intervention delivery, ineffective communication with emergency department staff, lack of privacy in the emergency department, the fast-paced emergency department setting, and patient’s limited resources. Together, these barriers represent the intervention characteristics, inner setting, and outer setting domains of the CFIR. Conclusion Results highlight the utility of employing an implementation science framework to assess implementation issues in pragmatic trials and how this approach might be used as a quality assurance mechanism given the considerable overlap that exists between research and intervention protocols in real-world trial settings. Previously undocumented changes to the trial design that have been made as a result of the identified barriers are discussed.
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Affiliation(s)
- Allyson L Dir
- Department of Psychiatry, Indiana University School of Medicine, 410 W 10th Street, Suite 2000, Indianapolis, IN, 46202, USA
| | - Dennis P Watson
- Lighthouse Institute, Chestnut Health Systems, 221 W Walton St., Chicago, IL, 60610, USA.
| | - Matthew Zhiss
- School of Social Work, Indiana University Purdue University Indianapolis, 902 West New York Street, Indianapolis, IN, 46202, USA
| | - Lisa Taylor
- Center for Dissemination and Implementation Science, Department of Medicine, College of Medicine, University of Illinois at Chicago, 818 S. Wolcott, Chicago, IL, 60612, USA
| | - Bethany C Bray
- Center for Dissemination and Implementation Science, Department of Medicine, College of Medicine, University of Illinois at Chicago, 818 S. Wolcott, Chicago, IL, 60612, USA
| | - Alan McGuire
- Department of Psychology, Indiana University Purdue University Indianapolis, 402 N. Blackford St., Indianapolis, IN, 46202, USA.,Center for Health Information and Communication, Health Services Research and Development, Richard L. Roudebush VAMC, 1481 W. 10th St. (11H) Rm. C8108, Indianapolis, IN, 46202, USA
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Loomer L, Ogarek JA, Mitchell SL, Volandes AE, Gutman R, Gozalo PL, McCreedy EM, Mor V. Impact of an Advance Care Planning Video Intervention on Care of Short-Stay Nursing Home Patients. J Am Geriatr Soc 2020; 69:735-743. [PMID: 33159697 DOI: 10.1111/jgs.16918] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES To assess whether an advance care planning (ACP) video intervention impacts care among short-stay nursing home (NH) patients. DESIGN PRagmatic trial of Video Education in Nursing Homes (PROVEN) was a pragmatic cluster randomized clinical trial. SETTING A total of 360 NHs (N = 119 intervention, N = 241 control) owned by two healthcare systems. PARTICIPANTS A total of 2,538 and 5,290 short-stay patients with advanced dementia or cardiopulmonary disease (advanced illness) in the intervention and control arms, respectively; 23,302 and 50,815 short-stay patients without advanced illness in the intervention and control arms, respectively. INTERVENTION Five ACP videos were available on tablets or online. Designated champions at each intervention facility were instructed to offer a video to patients (or proxies) on admission. Control facilities used usual ACP practices. MEASUREMENTS Follow-up time was at most 100 days for each patient. Outcomes included hospital transfers per 1000 person-days alive and the proportion of patients experiencing more than one hospital transfer, more than one burdensome treatment (tube-feeding, parenteral therapy, invasive mechanical intervention, and intensive care unit admission), and hospice enrollment. Champions recorded whether a video was offered in the patients' electronic medical record. RESULTS There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention versus control groups with advanced illness (rate (95% confidence interval (CI)), 12.3 (11.6-13.1) vs 13.2 (12.5-13.7); rate difference: -0.8; 95% CI = -1.8-0.2)). There was a nonsignificant reduction in hospital transfers per 1000 person-days alive in the intervention versus control among short-stay patients without advanced illness. Secondary outcomes did not differ between groups among patients with and without advanced illness. Based on champion only reports 14.2% and 15.3% of eligible short-stay patients with and without advanced illness were shown videos, respectively. CONCLUSION An ACP video program did not significantly reduce hospital transfers, burdensome treatment, or hospice enrollment among short-stay NH patients; however, fidelity to the intervention was low.
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Affiliation(s)
- Lacey Loomer
- Department of Economics, Labovitz School of Business and Economics, Duluth, Minnesota, USA
| | - Jessica A Ogarek
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Susan L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Angelo E Volandes
- General Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Section of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Pedro L Gozalo
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
| | - Ellen M McCreedy
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Vincent Mor
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
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