Building evidence to advance health equity: a systematic review on care-related outcomes for older, minoritised populations in long-term care homes

BACKGROUND

Advancing health equity requires more contextualised evidence.

OBJECTIVES

To synthesise published evidence using an existing framework on the origins of health disparities and determine care-related outcome disparities for residents of long-term care, comparing minoritised populations to the context-specific dominant population.

DESIGN

Systematic review.

SUBJECTS

Residents of 24-hour long-term care homes.

METHODS

The protocol was registered a priori with PROSPERO (CRD42021269489). Literature published between 1 January 2000 and 26 September 2021, was searched, including studies comparing baseline characteristics and outcomes in minoritised versus dominant populations. Dual screening, two-reviewer verification for extraction, and risk of bias assessments were conducted to ensure rigour. Studies were synthesized using a conceptual framework to contextualise evidence according to multi-level factors contributing to the development of care disparities.

RESULTS

Twenty-one of 34 included studies demonstrated disparities in care outcomes for minoritised groups compared to majority groups. Thirty-one studies observed differences in individual-level characteristics (e.g. age, education, underlying conditions) upon entry to homes, with several outcome disparities (e.g. restraint use, number of medications) present at baseline and remaining or worsening over time. Significant gaps in evidence were identified, particularly an absence of literature on provider information and evidence on the experience of intersecting minority identities that contribute to care-related outcome disparities in long-term care.

CONCLUSION

This review found differences in minoritised populations' care-related outcomes. The findings provide guidance for future health equity policy and research-supporting diverse and intersectional capacity building in long-term care.

Perceptions of Palliative and End-Of-Life Care Capacity Among Frontline Staff and Administrators in Long-Term Care Homes During the COVID-19 Pandemic in Ontario, Canada: A Mixed-Methods Evaluation

OBJECTIVES

The COVID-19 pandemic has greatly affected the morbidity and mortality of residents in long-term care (LTC) homes. However, not much is known about its impact on staff's perception of their capacity to provide palliative and end-of-life (EOL) care for LTC residents over the course of the pandemic. We investigated changes in self-reported confidence among LTC workers and their experience in providing palliative and EOL care to residents before and during the COVID-19 pandemic.

DESIGN

Mixed-methods evaluation using a survey (n = 19) and semistructured interviews (n = 28).

SETTING AND PARTICIPANTS

Frontline workers from 9 LTC homes who participated in Communication at End-of-Life Program in Ontario, Canada, between August 2019 and March 2020.

METHODS

The survey captured LTC staff's confidence level, including attitudes toward death and dying; relationships with residents and families; and participation in palliative and EOL care. The interviews identified facilitators and barriers to providing palliative and EOL care during the pandemic.

RESULTS

The COVID-19 pandemic negatively impacted frontline LTC staff's confidence in their role as palliative care providers. Participants also reported notable challenges to providing resident-centered palliative and EOL care. Specifically, visitation restriction has led to increased loneliness and isolation of residents and impeded staff's ability to build supportive relationships with families. Furthermore, staffing shortages due to the single-site work restriction and illness increased workload. Psychological stress caused by a fear of COVID-19 infection and transmission also hindered staff's capacity to provide good palliative and EOL care.

CONCLUSIONS AND IMPLICATIONS

Frontline LTC staff-even those who felt competent in their knowledge and skills in providing palliative and EOL care after receiving training-reported notable difficulties in providing resident-centered palliative and EOL care during the COVID-19 pandemic.

The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults

OBJECTIVE

In Canada, a persistent barrier to achieving healthcare system efficiency has been patient days accumulated by individuals with an alternate level of care (ALC) designation. Transitional care units (TCUs) may address the capacity pressures associated with ALC. We sought to assess the cost-effectiveness of a nursing home (NH) based TCU leveraging existing infrastructure to support a hospitalized older adult's transition to independent living at home.

METHODS

This case-control study included frail, older adults who received care within a function-focused TCU following a hospitalization between 1 March 2018 and 30 June 2019. TCU patients were propensity score matched to hospitalized ALC patients ("usual care"). The primary outcome was days without requiring institutional care six months following discharge, defined as institutional-free days. This was calculated by excluding all days in hospitals, rehabilitation facilities, complex continuing care facilities and NHs. Using the total direct cost of care up to discharge from TCU or hospital, the incremental cost-effectiveness ratio was calculated.

RESULTS

TCU patients spent, on average, 162.0 days institution-free (95% CI: 156.3-167.6d) within six months days post-discharge, while usual care patients spent 140.6 days institution-free (95% CI: 132.3-148.8d). TCU recipients had a lower total cost of care, by CAN$1,106 (95% CI: $-6,129-$10,319), due to the reduced hospital length of stay (mean [SD] 15.6d [13.3d] for TCU patients and 28.6d [67.4d] days for usual care). TCU was deemed the more cost-effective model of care.

LIMITATIONS

The main limitation was the potential inclusion of patients not eligible for SAFE in our usual group. To minimize this selection bias, we expanded the geographical pool of ALC patients to patients with SAFE admission potential in other area hospitals.

CONCLUSIONS

Through rehabilitative and restorative care, TCUs can reduce hospital length of stay, increase potential for independent living, and reduce risk for subsequent institutionalization.

[Multi-omics research contributes to early screening, diagnosis and treatment of liver cancer]

In 2016, the World Health Organization set an ambitious goal of reducing viral hepatitis-related deaths by 65% by 2030. The key to this goal is to reduce viral hepatitis-related HCC deaths. Liver cancer is the fourth most common malignant tumor and the second leading cause of cancer death in China. The onset of HCC is insidious, and most patients are already in the middle and late stage when diagnosed. Despite the great progress on management of HCC, the therapeutic effect and prognosis of HCC are still unsatisfactory. Therefore, multi-dimensional and comprehensive analysis of the mechanism of liver cancer, improving the early screening, diagnosis and treatment rate of liver cancer are the key points of reducing the harm of liver cancer in China. In recent years, multi-omics studies have been widely applied in the field of liver cancer, providing a basis for the pathogenesis of liver cancer, early detection and diagnosis, development of individual treatment strategies and prognosis assessment. This issue will focus on the application of genomics, proteomics, metabolomics and imaging omics in early screening, diagnosis and treatment of liver cancer.

An Evaluation of the Communication at End-of-Life Education Program for Personal Support Workers in Long-Term Care

Background: Communication skills are crucial for personal support workers (PSWs) to foster therapeutic relationships with the residents and their families in the long-term care (LTC) setting. Aim: To evaluate the impact of the Communication at End-of-Life (CEoL) Education Program on the competency and confidence of PSWs working in LTC to communicate about palliative and end-of-life care, and factors affecting their involvement in palliative and end-of-life care. Setting/Participants: PSWs from 35 LTC homes in Ontario, Canada, who participated in the CEoL Education Program between January and March 2019. Design: Mixed-methods evaluation using pre- (n = 178) and post-workshop (n = 113) surveys capturing the attitudes and beliefs toward death and dying; relationships with residents and families; and PSWs' participation in end-of-life care. Follow-up interviews were conducted between February and March 2019 with 21 PSWs to examine facilitators and barriers that affected their confidence in engaging in palliative care. Results: We observed significant improvements in all three domains, with the greatest increase (11%, p < 0.001) in the proportion of participants who responded "Often" or "Always" in the participation in end-of-life care domain. Specifically, we observed PSWs' elevated confidence in speaking with families of the residents about end-of-life, discussing goals and plans with the residents, and realizing that a "good death" is possible. Time constraints and staff shortages were recurrent themes that hindered many participants' ability to provide resident-centered care. Conclusions: This evaluation demonstrates that CEoL Education Program was associated with improved PSW competency and confidence in supporting palliative and end-of-life care in LTC settings.

Corticosteroid pharmacokinetics in the inner ear fluids: an animal study followed by clinical application

OBJECTIVE

Autoimmune disease (e.g., Cogan syndrome) and other inflammatory inner ear diseases may ravage the labyrinth if not treated aggressively with antiinflammatory medication. Corticosteroids are the mainstay of treatment, yet, partly because of the existence of the blood-labyrinthine barrier, the ideal drug, dose, and route of administration are currently unknown.

STUDY DESIGN

In the present study, we established cochlear fluid pharmacokinetic profiles of hydrocortisone, methylprednisolone, and dexamethasone in the guinea pig following oral, intravenous, and topical (intratympanic) administration. High-performance liquid chromatography was used to determine the drug concentrations, and comparisons were made with simultaneous pharmacokinetic profiles from blood and cerebrospinal fluid.

RESULTS

Our findings demonstrated a much higher penetration of all three drugs into the cochlear fluids following topical application as compared with systemic administration, with methylprednisolone showing the best profile.

DISCUSSION

The results suggested that intratympanic administration of corticosteroids might be more efficacious while avoiding high blood levels and therefore the deleterious side effects of systemic use.

CLINICAL APPLICATION

Thirty-seven patients with various inner ear disorders causing sensorineural hearing loss were subsequently treated using intratympanic corticosteroids, 20 with dexamethasone, and 17 with methlyprednisolone. Patients with immune-mediated hearing losses showed the best results, with notable improvement also seen in several cases of a "sudden deafness." No benefit was seen in patients with cochlear hydrops or those with sudden deterioration of a preexisting hearing loss. Three patients developed a transient otitis media related to the treatments, easily controlled with antibiotics. There were no cases of treatment-induced hearing loss and no permanent tympanic membrane perforations.

CONCLUSIONS

Overall injection of intratympanic corticosteroids for the treatment of hearing loss in inner ear disorders appears to be both safe and highly effective for certain disorders. The concept of this technique is supported by animal experimental data. The findings from the present study warrant further clinical application and experimental investigation.

Comparative perilymph permeability of cephalosporins and its significance in the treatment and prevention of suppurative labyrinthitis

Cephalosporins are nonototoxic antibiotics that provide excellent coverage for almost all bacteria that can cause suppurative labyrinthitis. In this study we performed comparative perilymph permeability determinations of the three cephalosporins that we deemed to have the most clinical potential in these varied situations. Perilymph pharmacokinetic profiles were established for ceftazidime, cefuroxime, and cefotaxime and its metabolite desacetylcefotaxime in 36 guinea pigs by using the technique of high-performance liquid chromatography. At 1, 2, 3, 4, and 6 hours after intravenous administration of the three cephalosporins at a dose of 100 mg/kg of body weight, ceftazidime consistently exhibited the highest perilymph concentration. Desacetylcefotaxime showed the next highest capacity for penetration into perilymph. Keeping in mind that the choice of drug for the treatment of suppurative labyrinthitis should be based foremost on culture and sensitivity studies, we consider ceftazidime to be the first-line agent for treatment and prevention of both meningogenic labyrinthitis and labyrinthitis complicating acute or chronic otitis media.

Pharmacokinetic profiles of ceftazidime in cochlear perilymph, cerebrospinal fluid and plasma: a high-performance liquid chromatographic study

A pharmacokinetic profile of the antibiotic ceftazidime was established for perilymph, cerbrospinal fluid (CSF) and plasma in 12 guinea pigs using the technique of high-performance liquid chromatography. The mean peak levels of 13.35 mg/l in perilymph and 140.54 mg/l in plasma were reached within the first hour after a single intravenous dose of 100 mg/kg. The CSF mean peak level of 5.36 mg/l, however, was not attained until 3 h after injection. The half-life was about 4 h in perilymph, more than 6 h in CSF and less than 2 h in plasma. Six hours following administration, the perilymph drug concentration remained higher than the plasma level. The study indicates that ceftazidime has excellent penetration into perilymph. It is concluded that ceftazidime should be a very useful agent in the treatment of bacterial labyrinthitis caused by susceptible organisms.

Teratoma of the middle ear

Teratomas are true tumours derived from ectoderm, mesoderm, and endoderm, which differentiate into identifiable tissues and organs. Teratomas of the temporal bone are exceedingly rare, but should be considered in the differential diagnosis of a temporal bone mass at birth or during childhood. We present a case of a temporal bone teratoma involving the middle ear, judge the imaging capabilities of computed tomography in the diagnosis, and review the literature.

Cefuroxime: pharmacokinetics in cochlear perilymph, cerebrospinal fluid, and plasma

Very little is known about the permeability of contemporary antibiotics through the blood:perilymph barrier. In this study, we measure the concentration of cefuroxime in perilymph, cerebrospinal fluid (CSF), and plasma in the guinea pig following intravenous administration by using the technique of high-performance liquid chromatography. The results of our study demonstrate a higher permeability of cefuroxime in perilymph than in CSF with a similar concentration profile over time in both fluids. This suggests that each of the two fluid compartments has its own drug barrier, with little or no free passage from CSF to perilymph. On the basis of these experimental findings, we feel that cefuroxime has considerable potential as an antibacterial agent for the treatment or prevention of bacterial labyrinthitis.

[Classification and treatment of torsades de pointes (TdP): a report of 11 cases]

A clinical analysis of 11 cases with TdP was reported. These patients were divided into two groups: 9 cases with long QT syndrome and 2 with normal QT interval. All of the patients suffered from coronary heart disease with various concomitant ailments, such as pulmonary heart disease (1 case), atrioventricular block (5 cases with complete or type II second degree AV block), hypokalemia (7 cases). In one case the TdP was caused by aminodarone administration. The principle of treatment included removing the inducing causes, treating the primary diseases and interrupting TdP. All patients who had hypokalemia were treated with potassium chloride. 7 of 9 cases showed effective response to treatment with magnesium sulfate. The patients with long QT syndrome failed to respond with MgSO4. Severe bradycardia should be treated with isoprenaline. Only one patient had pacing therapy and another received electric conversion. According to our experience, for patients of TdP with long QT syndrome class Ia and III antiarrhythmic agents were contraindicated, but those with normal QT interval can take these drugs.

Sudden sensorineural hearing loss induced by experimental iron deficiency in rats

The relation between iron deficiency (ID) and sudden sensorineural hearing loss (SSHL) was evaluated in the growing rats of three different experimental groups. Fourteen rats of 132 (10.61%) that were raised on a basic ID diet showed SSHL in varied extent, from moderate to profound. By contrast, none of 128 standard control and 126 anemic control rats that were fed with the final iron-supplemented diet showed any degree of SSHL. The main cochlear correlates of SSHL in ID rats were synchronous abnormalities of the iron-containing enzymatic activity in the whole cochlea, a significant reduction of spiral ganglion cells and a rapid involvement of stereocilia of the outer and inner hair cells. The results suggest that ID can play a major role in the pathogenesis of SSHL.

Idiopathic sudden hearing loss and disturbance of iron metabolism. A clinical survey of 426 cases

The role of disturbances of the iron metabolism (DIM) in idiopathic sudden hearing loss (ISHL) was investigated in 426 patients with ISHL who received iron therapy, anti-DIM medication, vitamins, and a combined regimen in a randomized study which was stratified by stages and groups. Low concentrations of haemoglobin, serum iron, serum ferritin, and red cell basic ferritin as well as abnormal circadian variations in the serum iron level were observed. The results were significantly better in patients receiving iron therapy than in those receiving anti-DIM medication, vitamins, and the combined regimen. Hearing improvement was achieved in 53.26% of the patients whose treatment started later than 3 months after the onset of the disease. The clinical association of DIM and ISHL is discussed.

Red cell basic ferritin concentration in sensorineural hearing loss

Red cell basic ferritin (RCBF) was measured in 62 healthy subjects with normal hearing and 224 patients with different kinds of sensorineural hearing loss, compared with serum ferritin, haemoglobin, serum iron and circadian variation in the serum iron levels. The results showed that the RCBF concentrations in most kinds of sensorineural hearing loss were significantly lower than those in normal hearing status. It is conceivable that the RCBF assay can be used to evaluate the adequacy of iron stores that are useful in times of urgent iron needs and to diagnose relative iron deficiency in those patients with some other normal laboratory assays related to iron metabolism.

Noise-induced hearing loss in iron-deficient rats

The role of iron deficiency in noise-induced hearing loss (NIHL) was evaluated in 64 rats of four different experimental groups. Iron-deficient rats (ID-rats) and normal rats (N-rats) were simultaneously exposed to a steady state white noise (20-10,000 Hz) at 110 dB SPL for 30 min. Unexposed ID- and N-rats served as controls. In N-rats the temporary threshold shifts (TTS) would have completely disappeared if the animals were allowed to survive for 72 h. No permanent threshold shift (PTS) was seen in any of the N-rats. The ultrastructural correlates in N-rats are stereocilia disarray and mitochondria swelling in outer hair cells (OHCs). The TTS in ID-rats were larger than those in the N-rats, and most ID-rats with larger threshold shifts showed varying degrees of PTSs at 11 days post-exposure. The ultrastructural correlates of NIHL in ID-rats are obvious pathology of the stereocilia, such as segmental coalescence of stereocilia of many continuous OHCs and fusion of the tips of stereocilia of OHCs, and a significant reduction of mitochondria as well as slight degeneration of nucleus in the OHCs. It is concluded that iron deficiency can provide a pathological basis for NIHL.

Changes in the cochlear iron enzymes and adenosine triphosphatase in experimental iron deficiency

The influences of iron deficiency on the cochlear iron enzymes and adenosine triphosphatase were studied in 68 iron-deficient rats and 68 control rats (normal and with chronic anemia). A disorderly or topographic distribution and reduction or disappearance of the cochlear succinic dehydrogenase and peroxidase reaction products were found in 37.8% of the rats fed on a basic iron-deficient diet for 14 to 100 days. The activity of cochlear sodium-potassium-dependent adenosine triphosphatase in iron-deficient rats was slightly increased, compared to that in normal controls. These results suggest that iron deficiency would produce significant abnormalities of succinic dehydrogenase and peroxidase activity, which in turn would disturb cell respiration and initiate peroxidative damage to the inner ear cells, result in sensorineural hearing loss, or provide a pathologic basis for cochlear deafness.

A scanning electron microscopic study of cochlear changes in iron-deficient rats

The effects of iron deficiency on the cochlea were studied in growing rats fed with a basic iron-deficient diet for 80 days. The electrophysiological changes (auditory thresholds raised more than 15 dB) were observed in 47% of the cochleas of iron-deficient rats. When these organs of Corti were examined by scanning electron microscopy, abnormalities of outer or inner hair cells were found, as follows: (1) fusion and torsion of the stereocilia, (2) coalescence of adjacent stereocilia in the same row, (3) loss of sensory hair stiffness, and (4) loss of stereocilia. Within each lesion, the neighbouring supporting cells and their microvilli showed no damage. The findings indicate that cochlear impairment can be induced by iron deficiency. The peroxidative mechanisms responsible for the lesions of stereocilia in iron deficiency are discussed.

Iron deficiency and hearing loss. Experimental study in growing rats

Cochlear changes were studied in 141 growing rats raised on a basic iron-deficient diet for 7-100 days; 130 rats served as normal or chronic anemia controls. Electrophysiological findings showed that the incidence of an auditory threshold elevation of more than 15 dB was 31.85% in the iron-deficient rats, but it was unchanged in all the control animals. The main cochlear histopathological changes induced by iron deficiency were strial atrophy and reduction of spiral ganglion cells. It is concluded that the observed anomalies may be attributed solely to iron deficiency of the cochlear tissue.