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Green AR, Quiles R, Daddato AE, Merrey J, Weffald L, Gleason K, Xue QL, Swarthout M, Feeser S, Boyd CM, Wolff JL, Blinka MD, Libby AM, Boxer RS. Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study. J Am Geriatr Soc 2024. [PMID: 38488757 DOI: 10.1111/jgs.18867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND People living with dementia (PLWD) have complex medication regimens, exposing them to increased risk of harm. Pragmatic deprescribing strategies that align with patient-care partner goals are needed. METHODS A pilot study of a pharmacist-led intervention to optimize medications with patient-care partner priorities, ran May 2021-2022 at two health systems. PLWD with ≥7 medications in primary care and a care partner were enrolled. After an introductory mailing, dyads were randomized to a pharmacist telehealth intervention immediately (intervention) or delayed by 3 months (control). Feasibility outcomes were enrollment, intervention completion, pharmacist time, and primary care provider (PCP) acceptance of recommendations. To refine pragmatic data collection protocols, we assessed the Medication Regimen Complexity Index (MRCI; primary efficacy outcome) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS). RESULTS 69 dyads enrolled; 27 of 34 (79%) randomized to intervention and 28 of 35 (80%) randomized to control completed the intervention. Most visits (93%) took more than 20 min and required multiple follow-up interactions (62%). PCPs responded to 82% of the pharmacists' first messages and agreed with 98% of recommendations. At 3 months, 22 (81%) patients in the intervention and 14 (50%) in the control had ≥1 medication discontinued; 21 (78%) and 12 (43%), respectively, had ≥1 new medication added. The mean number of medications decreased by 0.6 (3.4) in the intervention and 0.2 (1.7) in the control, reflecting a non-clinically meaningful 1.0 (±12.4) point reduction in the MRCI among intervention patients and a 1.2 (±12.9) point increase among control. FCMAHS scores decreased by 3.3 (±18.8) points in the intervention and 2.5 (±14.4) points in the control. CONCLUSION Though complex, pharmacist-led telehealth deprescribing is feasible and may reduce medication burden in PLWD. To align with patient-care partner goals, pharmacists recommended deprescribing and prescribing. If scalable, such interventions may optimize goal-concordant care for PLWD.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rosalphie Quiles
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrea E Daddato
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
| | | | - Linda Weffald
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Kathy Gleason
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
| | - Qian-Li Xue
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Scott Feeser
- Johns Hopkins Community Physicians, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marcela D Blinka
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anne M Libby
- Department of Emergency Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rebecca S Boxer
- Davis Department of Medicine, University of California, Sacramento, California, USA
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Daddato AE, Gleason KS, Dollar BA, McPhail TE, Kraus CR, Boxer RS. Understanding Experiences of Caregivers of Spouses with Dementia During Caregiver Healthcare Emergencies. Gerontologist 2024:gnad165. [PMID: 38205833 DOI: 10.1093/geront/gnad165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Caregivers of persons with dementia are frequently spouses. Caregiver hospitalization causes disruption to caregiving. The goal of this research was to understand the preparedness and stress trajectory peri-caregiver hospitalization. RESEARCH DESIGN AND METHODS Mixed methods were used. Caregivers of spouses with dementia (n=1000) were surveyed to determine their perceived preparedness for their own hospitalization. Journey mapping interviews (n=18) were used to map caregivers' experiences during five phases: 1) their spouse with dementia (SWD)'s dementia diagnosis, 2) their SWD's dementia progression, 3) their own health event, 4) their own hospitalization, and 5) their own return home from hospital. RESULTS Among the 452 (45%) eligible caregiver survey respondents, 75 (17%) had experienced a hospitalization in the previous 12 months and 51 (68%) hospitalizations were unexpected. Twenty-three (31%) of hospitalized caregivers indicated they did not have prior plans in place for the care of the SWD. When asked about an unexpected hospitalization in the future, 233 (52%) felt somewhat prepared and 133 (29%) felt not at all prepared. Journey mapping revealed three groups of caregivers: Group 1 (n=7) rated their stress lower during their hospitalization, Group 2 (n=7) rated their stress highest during their hospitalization, and Group 3 (n=4) were at a sustained high-stress level. DISCUSSION AND IMPLICATIONS Many caregivers are not prepared for their own hospitalization. The stress trajectory through important phases of dementia caregiving and a caregiver's own hospitalization is not universal. Meeting the needs of caregivers peri-hospitalization should be tailored to the individual caregiver.
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Affiliation(s)
- Andrea E Daddato
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Blythe A Dollar
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Tobie E McPhail
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Courtney R Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Rebecca S Boxer
- Department of Internal Medicine, University of California Davis, Sacramento, CA, USA
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Smith CL, Bednarchik B, Aung H, Wilk DJ, Boxer RS, Daddato AE, Wilson BM, Gravenstein S, Canaday DH. Humoral and Cellular Immunity Induced by Adjuvanted and Standard Trivalent Influenza Vaccine in Older Nursing Home Residents. J Infect Dis 2023; 228:704-714. [PMID: 36951196 DOI: 10.1093/infdis/jiad071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/07/2023] [Accepted: 03/21/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Despite wide use of adjuvanted influenza vaccine in nursing home residents (NHR), little immunogenicity data exist for this population. METHODS We collected blood from NHR (n = 85) living in nursing homes participating in a cluster randomized clinical trial comparing MF59-adjuvanted trivalent inactivated influenza vaccine (aTIV) with nonadjuvanted vaccine (TIV) (parent trial, NCT02882100). NHR received either vaccine during the 2016-2017 influenza season. We assessed cellular and humoral immunity using flow cytometry and hemagglutinin inhibition, antineuraminidase (enzyme-linked lectin assay), and microneutralization assays. RESULTS Both vaccines were similarly immunogenic and induced antigen-specific antibodies and T cells, but aTIV specifically induced significantly larger 28 days after vaccination (D28) titers against A/H3N2 neuraminidase than TIV. CONCLUSIONS NHRs respond immunologically to TIV and aTIV. From these data, the larger aTIV-induced antineuraminidase response at D28 may help explain the increased clinical protection observed in the parent clinical trial for aTIV over TIV in NHR during the A/H3N2-dominant 2016-2017 influenza season. Additionally, a decline back to prevaccination titers at 6 months after vaccination emphasizes the importance of annual vaccination against influenza. CLINICAL TRIALS REGISTRATION NCT02882100.
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Affiliation(s)
- Carson L Smith
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Beth Bednarchik
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Htin Aung
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Dennis J Wilk
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente of Colorado, Aurora, CO, USA
| | - Andrea E Daddato
- Institute for Health Research, Kaiser Permanente of Colorado, Aurora, CO, USA
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, USA
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Stefan Gravenstein
- Division of Geriatrics and Palliative Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, USA
| | - David H Canaday
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, USA
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Ha DM, Comer A, Dollar B, Bedoy R, Ford M, Gozansky WS, Zeng C, Arch JJ, Leach HJ, Malhotra A, Prochazka AV, Keith RL, Boxer RS. Telemedicine-based inspiratory muscle training and walking promotion with lung cancer survivors following curative intent therapy: a parallel-group pilot randomized trial. Support Care Cancer 2023; 31:546. [PMID: 37656252 PMCID: PMC10474183 DOI: 10.1007/s00520-023-07999-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Following curative-intent therapy of lung cancer, many survivors experience dyspnea and physical inactivity. We investigated the feasibility, acceptability, safety, and potential efficacy of inspiratory muscle training (IMT) and walking promotion to disrupt a postulated "dyspnea-inactivity" spiral. METHODS Between January and December 2022, we recruited lung cancer survivors from Kaiser Permanente Colorado who completed curative-intent therapy within 1-6 months into a phase-IIb, parallel-group, pilot randomized trial (1:1 allocation). The 12-week intervention, delivered via telemedicine, consisted of exercise training (IMT + walking), education, and behavior change support. Control participants received educational materials on general exercise. We determined feasibility a priori: enrollment of ≥ 20% eligible patients, ≥ 75% retention, study measure completion, and adherence. We assessed acceptability using the Telemedicine-Satisfaction-and-Usefulness-Questionnaire and safety events that included emergency department visits or hospitalizations. Patient-centered outcome measures (PCOMs) included dyspnea (University-of-California-San-Diego-Shortness-of-Breath-Questionnaire), physical activity (activPAL™ steps/day), functional exercise capacity (mobile-based-six-minute-walk-test), and health-related quality of life (HRQL, St.-George's-Respiratory-Questionnaire). We used linear mixed-effects models to assess potential efficacy. RESULTS We screened 751 patients, identified 124 eligible, and consented 31 (25%) participants. Among 28 participants randomized (14/group), 22 (11/group) completed the study (79% retention). Intervention participants returned > 90% of self-reported activity logs, completed > 90% of PCOMs, and attended > 90% of tele-visits; 75% of participants performed IMT at the recommended dose. Participants had high satisfaction with tele-visits and found the intervention useful. There was no statistically significant difference in safety events between groups. Compared to control participants from baseline to follow-up, intervention participants had statistically significant and clinically meaningful improved HRQL (SGRQ total, symptom, and impact scores) (standardized effect size: -1.03 to -1.30). CONCLUSIONS Among lung cancer survivors following curative-intent therapy, telemedicine-based IMT + walking was feasible, acceptable, safe, and had potential to disrupt the "dyspnea-inactivity" spiral. Future efficacy/effectiveness trials are warranted and should incorporate IMT and walking promotion to improve HRQL. TRIAL REGISTRATION ClinicalTrials.gov NCT05059132.
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Affiliation(s)
- Duc M Ha
- Institute for Health Research, Kaiser Permanente Colorado2550 S Parker Rd Suite 200, Aurora, CO, 80014, USA.
- Section of Pulmonary and Critical Care, Medical & Research Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA.
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Angela Comer
- Institute for Health Research, Kaiser Permanente Colorado2550 S Parker Rd Suite 200, Aurora, CO, 80014, USA
| | - Blythe Dollar
- Institute for Health Research, Kaiser Permanente Colorado2550 S Parker Rd Suite 200, Aurora, CO, 80014, USA
| | - Ruth Bedoy
- Institute for Health Research, Kaiser Permanente Colorado2550 S Parker Rd Suite 200, Aurora, CO, 80014, USA
| | - Morgan Ford
- Institute for Health Research, Kaiser Permanente Colorado2550 S Parker Rd Suite 200, Aurora, CO, 80014, USA
| | - Wendolyn S Gozansky
- Institute for Health Research, Kaiser Permanente Colorado2550 S Parker Rd Suite 200, Aurora, CO, 80014, USA
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado2550 S Parker Rd Suite 200, Aurora, CO, 80014, USA
| | - Joanna J Arch
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA
- Cancer Prevention and Control, University of Colorado Cancer Center, Aurora, CO, USA
| | - Heather J Leach
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California San Diego, San Diego, CA, USA
| | - Allan V Prochazka
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Robert L Keith
- Section of Pulmonary and Critical Care, Medical & Research Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rebecca S Boxer
- Division of Geriatrics, Hospice and Palliative Care Medicine, University of California Davis, Sacramento, CA, USA
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Kelly C, Gleason K, Drace M, Steiner JF, Schwartz P, Robinson R, Boxer RS. Participant perspectives on the impact of receiving medically tailored meals on post-hospitalization. Public Health Nurs 2023. [PMID: 36895127 DOI: 10.1111/phn.13184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/13/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE The objective of this program evaluation was to measure the impact of a medically tailored meals (MTM) intervention on participants' self-reported recovery and satisfaction while recovering from a recent hospitalization. DESIGN A qualitative design was employed using a brief survey among all participants at the end of the intervention and phone interviews with a subset of participants. SAMPLE Participants in this study were recently discharged from the hospital and were members of (redacted for review) who had received 2-4 weeks of MTM. MEASUREMENTS The survey assessed overall satisfaction with the meals and perceived impact on their recovery after hospitalization (81% response rate). Interview questions asked how they felt the meals may have helped while recovering (e.g., helped them financially or with their ability to remain independent). RESULTS Among survey participants, 65% were extremely or very satisfied with their meals. Reasons that MTM were helpful while they were recovering included having sufficient food to eat, having healthy food to eat, the convenience of the meals, and ease of preparing the meals. CONCLUSIONS Participants receiving MTM were generally very satisfied with the program. Including nutrition education and more flexibility in quantity and frequency of food may improve satisfaction and consumption of food.
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Affiliation(s)
- Cheryl Kelly
- Director of Evaluation, Measurement, and Regulatory Reporting, Kaiser Permanente, National Office of Community Health, Oakland, California
| | - Kathy Gleason
- Kaiser Permanente, Institute for Health Research, Aurora, Colorado
| | - Melanie Drace
- Kaiser Permanente, Institute for Health Research, Aurora, Colorado
| | - John F Steiner
- Kaiser Permanente, Institute for Health Research, Aurora, Colorado
| | - Pam Schwartz
- Kaiser Permanente, National Office of Community Health, Oakland, California
| | | | - Rebecca S Boxer
- Kaiser Permanente, Institute for Health Research, Aurora, Colorado
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Boxer RS, Daddato AE, Jessen A, Portz JD, Shetterly S. Hospitalizations of Caregivers Increases Risk of Hospitalization for Patients Living with Dementia. J Gen Intern Med 2023; 38:502-507. [PMID: 36376629 PMCID: PMC9905325 DOI: 10.1007/s11606-022-07902-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.
| | - Andrea E Daddato
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Andrew Jessen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jennifer D Portz
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Susan Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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Abstract
OBJECTIVES The perspectives of professionals involved in behavioral health (BH) services with short-stay residents in skilled nursing facilities (SNFs) are rarely captured in the literature. This study examines the real-world experiences of BH clinicians and administrators in post-acute/subacute care units in SNFs. METHODS This qualitative study used semi-structured interviews with 18 clinicians (e.g., psychologists and social workers) and five administrators (e.g., directors of social services or BH company executives) involved in BH services with short-stay SNF residents. Interviews were recorded, transcribed, and analyzed by two independent coders using conventional thematic content analysis. RESULTS Three themes emerged from the data: (1) BH needs are high among short-stay residents and families during post-acute care transitions; (2) BH services offer multiple unique opportunities to enhance post-acute/subacute care in SNFs; and (3) barriers to providing optimal BH care exist at multiple levels and require action from BH clinicians and stakeholders. CONCLUSIONS Variability in clinician roles and barriers to optimized care suggest the need for future research targeting best practices and implementation strategies for BH services with short-stay SNF residents. CLINICAL IMPLICATIONS Results identified multiple ways in which BH services may enhance resident, family, and staff outcomes, as well as the milieu in SNFs.
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Affiliation(s)
- Evan Plys
- Department of Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus
| | | | | | - Jennifer D. Portz
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus
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Morrow CD, Perraillon MC, Wald HL, Nelson JL, Reeder BP, Battaglia C, Boxer RS. Challenges in Heart Failure Disease Management in Skilled Nursing Facilities: A Qualitative Study. J Gerontol Nurs 2022; 48:14-17. [PMID: 35511061 DOI: 10.3928/00989134-20220404-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Clinical guidelines recommend clinicians in skilled nursing facilities (SNFs) monitor body weight and signs and symptoms related to heart failure (HF) and encourage a sodium restricted diet to improve HF outcomes; however, SNFs face considerable challenges in HF disease management (HF-DM). In the current study, we characterized the challenges of HF-DM with data from semi-structured, in-depth interviews with patients, caregivers, staff, and physicians from nine SNFs. Patients receiving skilled nursing care were interviewed together as a dyad with their caregiver. A data-driven, qualitative descriptive approach was used to understand the process and challenges of HF-DM. Coded text was categorized into descriptive themes. Interviews with five dyads (n = 10 individuals), SNF nurses and certified nursing assistants (n = 13), and physicians (n = 2) revealed that, among the sample, HF care was not prioritized above other competing health concerns. Staff operated in the challenging SNF environment largely without protocols or educational materials to prompt HF-DM. [Journal of Gerontological Nursing, 48(5), 13-17.].
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Weerahandi H, Chaussee EL, Dodson JA, Dolansky M, Boxer RS. Disease Management in Skilled Nursing Facilities Improves Outcomes for Patients With a Primary Diagnosis of Heart Failure. J Am Med Dir Assoc 2022; 23:367-372. [PMID: 34478693 PMCID: PMC8885787 DOI: 10.1016/j.jamda.2021.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). Our objective was to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP). DESIGN This is a subgroup analysis of multisite, physician and practice blocked, cluster-randomized controlled trial of HF-DMP vs usual care for patients in SNF with an HF diagnosis. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by an HF nurse advocate. SETTING AND PARTICIPANTS Patients with a primary hospital discharge diagnosis of HF discharged to SNF. METHODS Composite outcome of all-cause hospitalization, emergency department visits, and mortality were evaluated at 30 and 60 days post SNF admission. Linear mixed models accounted for patient clustering at the physician level. RESULTS Of 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79 ± 10 years, 53% women, and mean ejection fraction 46% ± 15%. At 60 days post SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared with usual care (52%) (P = .02). The rate of the composite outcome at 30 days for the HF-DMP group was 18% vs 31% in the usual care group (P = .11). CONCLUSIONS AND IMPLICATIONS Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while cared for in an SNF had lower rates of the composite outcome at 60 days. Standardized HF management during SNF stays may be important for patients with a primary discharge diagnosis of HF.
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Affiliation(s)
- Himali Weerahandi
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA; Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA; Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, NY, USA.
| | | | - John A. Dodson
- Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, NY,Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY
| | - Mary Dolansky
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH
| | - Rebecca S. Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO,Division of Geriatric Medicine, University of Colorado, Aurora, CO
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Wherry SJ, Blatchford PJ, Swanson CM, Wellington T, Boxer RS, Kohrt WM. Maintaining serum ionized calcium during brisk walking attenuates the increase in bone resorption in older adults. Bone 2021; 153:116108. [PMID: 34252605 PMCID: PMC8478867 DOI: 10.1016/j.bone.2021.116108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/26/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Endurance exercise can cause a decrease in serum ionized calcium (iCa) and increases in parathyroid hormone (PTH) and bone resorption, reflected by serum carboxy-terminal collagen crosslinks (CTX). We developed a calcium clamp to prevent the decrease in iCa during exercise, which attenuated increases in PTH and CTX during vigorous cycling in young men. The goal was to determine whether this occurs in older adults during brisk walking. METHODS Twelve older adults (6 men, 6 women) performed two identical 60-min treadmill walking bouts with Ca gluconate or half-normal saline infusion. Blood sampling for iCa, total calcium (tCa), phosphate (P), PTH, and CTX, occurred before, during, and for 4 h after exercise. RESULTS iCa decreased during exercise with the saline infusion (p = 0.04) and this provoked increases in PTH and CTX (both p < 0.01). The Ca clamp prevented the decrease in serum iCa during exercise and attenuated the PTH and CTX responses. CONCLUSIONS Preventing the exercise-induced decrease in iCa markedly attenuated the increases in PTH and CTX. The cause of the decrease in iCa during exercise remains unclear, but the increases in PTH and CTX are likely counter-regulatory responses to defend serum iCa. This contention is supported by previous observations that the disruption of Ca homeostasis during exercise occurs regardless of training status. It will be important to establish whether this acute catabolic effect of exercise diminishes the potential chronic anabolic effects of exercise on bone.
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Affiliation(s)
- Sarah J Wherry
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America; VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO 80045, United States of America.
| | - Patrick J Blatchford
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO 80045, United States of America; Department of Biostatistics and Bioinformatics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Christine M Swanson
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Toby Wellington
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Rebecca S Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America; VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO 80045, United States of America
| | - Wendy M Kohrt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America; VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO 80045, United States of America
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Chauhan L, Pattee J, Ford J, Thomas C, Lesteberg K, Richards E, Bernas CA, Loi M, Dumont L, Annen K, Berg M, Zirbes M, Knight V, Miller A, Jenkins TC, Bennett TD, Monkowski D, Boxer RS, Beckham JD. A Multi-center, Prospective, Observational-cohort controlled study of Clinical Outcomes following COVID-19 Convalescent plasma therapy in hospitalized COVID-19 patients. Clin Infect Dis 2021; 75:e466-e472. [PMID: 34549274 DOI: 10.1093/cid/ciab834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The SARS-CoV2 pandemic has caused high inpatient mortality and morbidity throughout the world. COVID19 convalescent plasma has been utilized as a potential therapy for patients hospitalized with COVID19 pneumonia. This study evaluated the outcomes of hospitalized COVID19 patients treated with COVID19 convalescent plasma in a prospective, observational multicenter trial. METHODS From April 2020 through August 2020, hospitalized COVID19 patients at 16 participating hospitals in Colorado were enrolled and treated with COVID19 convalescent plasma (CCP) and compared to hospitalized patients with COVID19 who were not treated with convalescent plasma. Plasma antibody levels were determined following the trial given that antibody tests were not approved at the initiation of the trial. CCP-treated and untreated COVID19 hospitalized patients were matched using propensity scores followed by analysis for length of hospitalization and inpatient mortality. RESULTS 542 total hospitalized COVID19 patients were enrolled at 16 hospitals across the region. A total of 468 hospitalized COVID19 patients were entered into propensity score matching with 188 patients matched for analysis in the CCP-treatment and control arms. Fine-Gray models revealed increased length of hospital stay in CCP-treated patients and no change in inpatient mortality compared to controls. In subgroup analysis of CCP-treated patients within 7 days of admission, there was no difference in length of hospitalization and inpatient mortality. CONCLUSIONS These data show that treatment of hospitalized COVID19 patients with CCP did not significantly improve patient hospitalization length of stay or inpatient mortality.
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Affiliation(s)
- Lakshmi Chauhan
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO.,University of Colorado School of Medicine, Aurora, CO
| | - Jack Pattee
- Center for Innovative Design and Analysis, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Joshay Ford
- University of Colorado School of Medicine, Aurora, CO
| | - Chris Thomas
- University of Colorado School of Medicine, Aurora, CO
| | - Kelsey Lesteberg
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | | | | | - Larry Dumont
- University of Colorado School of Medicine, Aurora, CO.,Vitalant Research Institute, Denver, CO
| | - Kyle Annen
- Children's Hospital Colorado, Aurora, CO
| | - Mary Berg
- University of Colorado Hospital System, CO
| | - Mercedes Zirbes
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Amanda Miller
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Tellen D Bennett
- Children's Hospital Colorado, Aurora, CO.,Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO.,Department of Pediatrics, Section of Informatics and Data Science, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente of Colorado, Aurora, CO
| | - J David Beckham
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO.,University of Colorado School of Medicine, Aurora, CO.,Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO
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12
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Plys E, Morrow CD, Portz JD, Jones CD, Piper C, Boxer RS. Psychological interventions with older adults during inpatient postacute rehabilitation: A systematic review. Rehabil Psychol 2021; 66:233-247. [PMID: 34472922 PMCID: PMC8622202 DOI: 10.1037/rep0000383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: Older adults in inpatient postacute care settings report high rates of depression and anxiety. Psychological interventions address these symptoms through educational, cognitive, behavioral, relaxation, and/or psychosocial approaches. The purpose of this study was to systematically evaluate the quality of existing literature on psychological interventions for depression and/or anxiety among older adults during an inpatient postacute care stay. Method: Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Google Scholar were searched for key concepts. Studies were included that (a) sampled skilled nursing facility or inpatient rehabilitation facility patients, (b) evaluated a psychological intervention, (c) measured depression and/or anxiety symptoms before and after interventions, and (d) had a mean or median age of 65+. Two raters assessed articles for inclusion and risk of bias. Results: Search strategies identified 7,506 articles for screening; nine met inclusion criteria. Included studies varied by study design, intervention type, and methodological quality. Only one study had low overall risk of bias. Four studies demonstrated preliminary treatment benefits for depression symptoms; none reported benefits for anxiety symptoms. Conclusions: Most of the included studies were limited by small sample size and high risk of bias. Thus, currently, there is insufficient evidence to support the effectiveness of psychological interventions for depression or anxiety among older adults during an inpatient postacute care stay. The authors offer a detailed discussion of methodological limitations, empirical gaps, and future directions to develop this body of literature. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Evan Plys
- Department of Psychiatry, University of Colorado School of Medicine
| | - Cynthia D Morrow
- Health Systems Management and Policy, Colorado School of Public Health
| | - Jennifer D Portz
- Division of General Internal Medicine, University of Colorado School of Medicine
| | - Christine D Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System
| | - Christi Piper
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente of Colorado
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13
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Boxer RS, Dolansky MA, Chaussee EL, Campbell JD, Daddato AE, Page RL, Fairclough DL, Gravenstein S. A Randomized Controlled Trial of Heart Failure Disease Management vs Usual Care in Skilled Nursing Facilities. J Am Med Dir Assoc 2021; 23:359-366. [PMID: 34146521 DOI: 10.1016/j.jamda.2021.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 05/14/2021] [Accepted: 05/19/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Patients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF. DESIGN Cluster-randomized controlled trial. PARTICIPANTS The trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care). METHODS The HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome. RESULTS Mean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant. CONCLUSIONS AND IMPLICATIONS The composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.
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Affiliation(s)
- Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente, Aurora, CO, USA; Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Mary A Dolansky
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Erin L Chaussee
- Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA; Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jon D Campbell
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Andrea E Daddato
- Institute for Health Research, Kaiser Permanente, Aurora, CO, USA; Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert L Page
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Diane L Fairclough
- Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA; Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stefan Gravenstein
- Alpert Medical School of Brown University, Providence, RI, USA; Brown School of Public Health, Providence, RI, USA; Providence Veterans Administration Medical Center, Providence, RI, USA
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14
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Stutzbach JA, Gustavson AM, Derlein DL, Forster JE, Boxer RS, Stevens-Lapsley JE. Older adults in skilled nursing facilities demonstrate low physical activity during and after discharge. Disabil Rehabil 2021; 44:3909-3914. [PMID: 33836134 DOI: 10.1080/09638288.2021.1892838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE This study sought to quantify physical activity and sedentary time among older adults during a skilled nursing facility (SNF) stay and after the transition home, a critical period when patients are at high risk for adverse events. MATERIALS AND METHODS We performed an observational cohort study of physical activity and sedentary behavior during the last 3-5 days before discharge from SNF and the initial 3-5 days at home using accelerometers. Participants answered questions about perceived physical activity in the SNF and at home. RESULTS A convenience sample of thirty-one residents from two SNFs were included. Participants spent a median 12.2% (interquartile range [IQR], 17.3%) of time upright in the SNF and 16.8% (IQR, 15.2%) of their time upright at home (p = 0.002) and took a median of 849 steps (IQR, 1772) in the SNF and 922 steps (IQR, 1906) at home (p = 0.57), per day. Participants averaged fewer sitting bouts at home (p = 0.03), but there was no difference in sit-to-stand transitions (p = 0.32) or activity scores (p = 0.67). Subjective perceptions of physical activity appeared to be higher than objective measurements. CONCLUSION In an exploratory study, SNF residents demonstrated profoundly low levels of physical activity both during and after their SNF stay. Future studies using larger sample sizes should examine physical activity during the SNF to home transition as well as barriers and facilitators to physical activity in post-acute care environments.IMPLICATIONS FOR REHABILITATIONSNF residents in this study demonstrated low levels of physical activity and high rates of sedentary behavior that persisted after discharge home.Interventions to improve physical activity levels in the SNF are sorely needed, and those interventions should include a plan for progressing physical activity after the transition home.Objective measurement of physical activity using activity monitors may prove clinically useful for older adults following hospitalization in the SNF and home settings.
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Affiliation(s)
- Julie A Stutzbach
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Allison M Gustavson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Danielle L Derlein
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Jeri E Forster
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Rebecca S Boxer
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA.,Eastern Colorado VA Geriatric Research Education and Clinical Center (GRECC), Aurora, CO, USA
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15
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Morrow CD, Reeder BP, Perraillon MC, Ozkaynak M, Wald HL, Eber LE, Trojanowski JI, Battaglia C, Boxer RS. Information Needs of Skilled Nursing Facility Staff to Support Heart Failure Disease Management. AMIA Annu Symp Proc 2021; 2020:878-885. [PMID: 33936463 PMCID: PMC8075486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Characterize key tasks and information needs for heart failure disease management (HF-DM) in the distinct care setting of skilled nursing facility (SNF) staff in partnership with community-based clinical stakeholders. Develop design recommendations contextualized to the SNF setting for informatics interventions for improved HF-DM in the SNF setting. METHODS Semi-structured interviews with fifteen participants (registered nurses, licensed practical nurses, certified nursing aides and physicians) from 8 Denver-metro SNFs. Data coded using a data-driven, inductive approach. RESULTS Key tasks of HF-DM: symptom assessment, communicating change in condition, using equipment, documentation of daily weights, and monitoring patients. Themes: 1) HF-DM is challenged by a culture of verbal communication; 2) staff face knowledge barriers in HF-DM that are partially attributed to unmet information needs. HF-DM information needs: identification of HF patients, HF signs and symptoms, purpose of daily weights, indicators of worsening HF, purpose of sodium restricted diet, and materials to improve patients' understanding of HF. DISCUSSION AND CONCLUSIONS HF-DM information needs are not fully supported by current SNF information systems.
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Affiliation(s)
| | - Blaine P Reeder
- Sinclair School of Nursing, University of Missouri, Columbia, MO
- MU Institute for Data Science and Informatics, University of Missouri, Columbia, MO
| | | | | | | | | | | | | | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente, Aurora, CO
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16
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Portz JD, Ford KL, Doyon K, Bekelman DB, Boxer RS, Kutner JS, Czaja S, Bull S. Using Grounded Theory to Inform the Human-Centered Design of Digital Health in Geriatric Palliative Care. J Pain Symptom Manage 2020; 60:1181-1192.e1. [PMID: 32615298 PMCID: PMC7323666 DOI: 10.1016/j.jpainsymman.2020.06.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 01/11/2023]
Abstract
CONTEXT Digital health offers innovative mechanisms to engage in palliative care, yet digital systems are typically designed for individual users, rather than integrating the patient's caregiving "social convoy" (i.e., family members, friends, neighbors, formal caregiving supports) to maximize benefit. As older adults with serious illness increasingly rely on the support of others, there is a need to foster effective integration of the social convoy in digitally supported palliative care. OBJECTIVES Conduct a qualitative study examining patient, social convoy, and health care provider perspectives on digital health for palliative care to inform the design of future digital solutions for older adults with serious illness and their social convoy. METHODS Grounded theory approach using semi-structured interviews (N = 81) with interprofessional health care providers, older adults with serious illness, and their social convoy participants at home, clinic, or Zoom. Interviews were conducted using question guides relevant to the participant group and audio-recorded for verbatim transcription. Two coders lead the inductive analysis using open and axial coding. RESULTS Thematic results aligned with the human-centered design framework, which is a participatory approach to the design process that incorporates multiple user stakeholders to develop health solutions. The human-centered design process and corresponding theme included the following: 1) Empathy: Patient, Caregiver, and Provider Experience reports participants' experience with managing serious illness, caregiving, social support, and technology use. 2) Define: Reactions to Evidence-Based Care Concepts and Barriers illustrates participants' perspectives on the domains of palliative care ranging from symptom management to psychosocial-spiritual care. 3) Ideation: Desired Features reports participant recommendations for designing digital health tools for palliative care domains. CONCLUSION Digital health provides an opportunity to expand the reach of geriatric palliative care interventions. This paper documents human-centered preferences of geriatric palliative care digital health to ensure technologies are relevant and meaningful to health care providers, patients, and the caregiving social convoy.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA; mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Kelsey Lynett Ford
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Katherine Doyon
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA
| | - David B Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA; Department of Medicine, Eastern Colorado Health Care System, Aurora, Colorado, USA; Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Rebecca S Boxer
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sara Czaja
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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17
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Portz JD, Ford KL, Elsbernd K, Knoepke CE, Flint K, Bekelman DB, Boxer RS, Bull S. "I Like the Idea of It…But Probably Wouldn't Use It" - Health Care Provider Perspectives on Heart Failure mHealth: Qualitative Study. JMIR Cardio 2020; 4:e18101. [PMID: 32885785 PMCID: PMC7501581 DOI: 10.2196/18101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/10/2020] [Accepted: 07/13/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Many mobile health (mHealth) technologies exist for patients with heart failure (HF). However, HF mhealth lacks evidence of efficacy, caregiver involvement, and clinically useful real-time data. OBJECTIVE We aim to capture health care providers' perceived value of HF mHealth, particularly for pairing patient-caregiver-generated data with clinical intervention to inform the design of future HF mHealth. METHODS This study is a subanalysis of a larger qualitative study based on interviewing patients with HF, their caregivers, and health care providers. This analysis included interviews with health care providers (N=20), focusing on their perceived usefulness of HF mHealth tools and interventions. RESULTS A total of 5 themes emerged: (1) bio-psychosocial-spiritual monitoring, (2) use of sensors, (3) interoperability, (4) data sharing, and (5) usefulness of patient-reported outcomes in practice. Providers remain interested in mHealth technologies for HF patients and their caregivers. However, providers report being unconvinced of the clinical usefulness of robust real-time patient-reported outcomes. CONCLUSIONS The use of assessments, sensors, and real-time data collection could provide value in patient care. Future research must continually explore how to maximize the utility of mHealth for HF patients, their caregivers, and health care providers.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, United States.,mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kelsey Lynett Ford
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kira Elsbernd
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Christopher E Knoepke
- Division of Cardiology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, United States.,Data Science to Patient Value (D2V) Initiative, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, United States.,Adult & Child Consortium for Outcomes Research & Delivery Science, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, United States
| | - Kelsey Flint
- Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs, Aurora, CO, United States
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, United States.,Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs, Aurora, CO, United States
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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18
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Gustavson AM, Malone DJ, Boxer RS, Forster JE, Stevens-Lapsley JE. Application of High-Intensity Functional Resistance Training in a Skilled Nursing Facility: An Implementation Study. Phys Ther 2020; 100:1746-1758. [PMID: 32750132 PMCID: PMC7530575 DOI: 10.1093/ptj/pzaa126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 08/20/2019] [Accepted: 04/24/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Rehabilitation in skilled nursing facilities (SNFs) is under scrutiny to deliver high-quality care and superior outcomes in less time. High-intensity resistance training demonstrates functional improvements in community-dwelling and long-term care populations but has not been generalized to the SNF population. The purpose of this study was to evaluate implementation issues including safety and feasibility and to provide preliminary information on effectiveness of rehabilitation focused on high-intensity functional resistance training in an SNF. METHODS The implementation study design consisted of 2 nonrandomized independent groups (usual care and high intensity) that were staged within a single SNF. The i-STRONGER program (IntenSive Therapeutic Rehabilitation for Older Skilled NursinG HomE Residents) integrates principles of physiologic tissue overload into rehabilitation. Physical therapists administered the Short Physical Performance Battery and gait speed at evaluation and discharge. Reach, Effectiveness, Adoption, Implementation, and Maintenance was used to evaluate the implementation process. An observational checklist and documentation audits were used to assess treatment fidelity. Regression analyses evaluated the response of functional change by group. RESULTS No treatment-specific adverse events were reported. Treatment fidelity was high at >99%, whereas documentation varied from 21% to 50%. Patient satisfaction was greater in i-STRONGER, and patient refusals to participate in therapy sessions trended downward in i-STRONGER. Patients in i-STRONGER exhibited a 0.13 m/s greater change in gait speed than in the usual care group. Although not significant, i-STRONGER resulted in a 0.64-point greater change in the Short Physical Performance Battery than usual care, and average SNF length of stay was 3.5 days shorter for i-STRONGER patients. CONCLUSION The findings from this study indicate that implementation of a high-intensity resistance training framework in SNFs is safe and feasible. Furthermore, results support a signal effectiveness of improving function and satisfaction, although the heterogeneity of the population necessitates a larger implementation study to confirm. IMPACT STATEMENT This pragmatic study demonstrates that high-intensity resistance training in medically complex older adults is safe and favorable in SNFs. This work supports the need to fundamentally change the intensity of rehabilitation provided to this population to promote greater value within post-acute care. Furthermore, this study supports the application of implementation science to rehabilitation for rapid and effective translation of evidence into practice.
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Affiliation(s)
- Allison M Gustavson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado
| | - Daniel J Malone
- CCS, Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado
| | - Rebecca S Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, and Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado
| | - Jeri E Forster
- Rocky Mountain Regional Veterans Affairs Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora; Department of Physical Medicine and Rehabilitation, University of Colorado; and Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
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19
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Portz JD, Lum HD, Bull S, Boxer RS, Bekelman DB, Ford KL, Gleason K, Casillas A, Bayliss EA. Perceptions of Patient Portal Use for Advance Directive Documentation among Older Adults with Multiple Chronic Conditions. J Soc Work End Life Palliat Care 2020; 16:238-249. [PMID: 32482160 PMCID: PMC9205613 DOI: 10.1080/15524256.2020.1771806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Patient portals can play an innovative role in facilitating advanced care planning (ACP) and documenting advance directives (ADs) among older adults with multiple chronic conditions. The objective of this qualitative sub-study was to (1) understand older adults' use of an ACP patient portal section and (2) obtain user-design input on AD documentation features. Although some older adults may be reluctant, participants reported likely to use a portal for ADs with proper portal design and support.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Hillary D. Lum
- Division of Geriatric Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
- VA Eastern Colorado Health Care System, Denver, Colorado
| | - Sheana Bull
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rebecca S. Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - David B. Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
- VA Eastern Colorado Health Care System, Denver, Colorado
| | - Kelsey L. Ford
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kathy Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
- Department of Family Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
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20
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Kohrt WM, Wolfe P, Sherk VD, Wherry SJ, Wellington T, Melanson EL, Swanson CM, Weaver CM, Boxer RS. Dermal Calcium Loss Is Not the Primary Determinant of Parathyroid Hormone Secretion during Exercise. Med Sci Sports Exerc 2020; 51:2117-2124. [PMID: 31009423 DOI: 10.1249/mss.0000000000002017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Exercise can cause a decrease in serum ionized calcium (iCa) concentration, which stimulates parathyroid hormone (PTH) secretion and activates bone resorption. We postulated that dermal Ca loss during cycling exercise is the major determinant of the serum iCa, PTH, and bone resorption (C-terminal telopeptide of type 1 collagen [CTX]) responses. METHODS To investigate this, women (n = 13) and men (n = 12) age 18 to 45 yr performed the same exercise bout under cool (18°C) and warm (26°C) conditions. Exercise was 60 min of cycling at ~75% of peak aerobic power. Sweat samples were obtained during exercise using a skin patch method, and blood samples were obtained before and during exercise and during 60 min of recovery. RESULTS Sweat volume and estimated sweat Ca loss were 50% higher for the warm condition than the cool condition. Despite this, there were no differences between thermal conditions in the changes (mean, 95% confidence interval [95% CI]) in iCa (cool, -0.07 mg·dL; 95% CI, -0.16 to 0.03); warm, -0.07 mg·dL; 95% CI, -0.20 to 0.05), PTH (cool, 34.4 pg·mL; 95% CI, 23.6-45.2; warm: 35.8 pg·mL; 95% CI, 22.4-49.1), or CTX (cool, 0.11 ng·mL; 95% CI, 0.08-0.13; warm, 0.15 ng·mL; 95% CI, 0.11-0.18). Adjusting for exercise-related shifts in plasma volume revealed a marked decline in vascular iCa content in the first 15 min of exercise (cool, -0.85 mg·dL; 95% CI, -1.01 to -0.68; warm, -0.85 mg·dL; 95% CI, -1.05 to -0.66), before substantial sweat Ca loss had occurred. CONCLUSIONS This indicates that dermal Ca loss was not the primary trigger for the increases in PTH and CTX during exercise. Further research is necessary to understand the causes and consequences of the disruption in Ca homeostasis during exercise and specifically the extravascular shift in iCa.
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Affiliation(s)
- Wendy M Kohrt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO.,Eastern Colorado VA Geriatric Research, Education, and Clinical Center, Aurora, CO
| | - Pamela Wolfe
- Department of Preventive Medicine and Biometrics, University of Colorado Denver, Aurora, CO
| | - Vanessa D Sherk
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Sarah J Wherry
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO.,Eastern Colorado VA Geriatric Research, Education, and Clinical Center, Aurora, CO
| | - Toby Wellington
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Edward L Melanson
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO.,Eastern Colorado VA Geriatric Research, Education, and Clinical Center, Aurora, CO.,Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Christine M Swanson
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Connie M Weaver
- Department of Nutrition Science, Purdue University, West Lafayette, IN
| | - Rebecca S Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO.,Eastern Colorado VA Geriatric Research, Education, and Clinical Center, Aurora, CO
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Jones CD, Nearing KA, Burke RE, Lum HD, Boxer RS, Stevens-Lapsley JE, Ozkaynak M, Levy CR. "What Would It Take to Transform Post-Acute Care?" 2019 Conference Proceedings on Re-envisioning Post-Acute Care. J Am Med Dir Assoc 2020; 21:1012-1014. [PMID: 32192872 DOI: 10.1016/j.jamda.2020.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/23/2020] [Accepted: 02/03/2020] [Indexed: 01/06/2023]
Affiliation(s)
- Christine D Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, CO.
| | - Kathryn A Nearing
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Eastern Colorado VA Geriatric Research Education and Clinical Center, Aurora, CO
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA; Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Eastern Colorado VA Geriatric Research Education and Clinical Center, Aurora, CO
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Jennifer E Stevens-Lapsley
- Eastern Colorado VA Geriatric Research Education and Clinical Center, Aurora, CO; Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Mustafa Ozkaynak
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Cari R Levy
- Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, CO; Division of Health Care Policy and Research, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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22
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Harper SA, Baptista LC, Roberts LM, Wherry SJ, Boxer RS, Hildreth KL, Seay RS, Allman PH, Carter CS, Aban I, Kohrt WM, Buford TW. Angiotensin Converting Enzyme Inhibitors Combined with Exercise for Hypertensive Seniors (The ACES Trial): Study Protocol of a Randomized Controlled Trial. Front Med (Lausanne) 2020; 6:327. [PMID: 32039215 PMCID: PMC6988302 DOI: 10.3389/fmed.2019.00327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/19/2019] [Indexed: 01/13/2023] Open
Abstract
Prior evidence suggests that the choice of antihypertensive medication may influence functional status among older adults with hypertension, particularly in conjunction with exercise. In particular, angiotensin converting enzyme (ACE) inhibitors have shown potential to positively influence function. However, randomized, controlled trials are needed to confirm this hypothesis. This paper outlines an RCT designed to determine if choice of first-line antihypertensive medication influences functional and cardiovascular risk factor responses to exercise among older adults with hypertension. Two hundred and thirteen inactive, community-dwelling adults ≥60 years of age with hypertension and functional limitations will be recruited to engage in a 32-week intervention study. Participants will be randomized to one of three first-line antihypertensive agents: (1) the ACE inhibitor perindopril, (2) the AT1 receptor antagonist losartan, or (3) the thiazide diuretic hydrochlorothiazide (HCTZ). Six weeks after randomization, participants will begin a 20-week structured aerobic exercise intervention. Participants will perform two 45-min center-based sessions coupled with 60 min of home-based walking per week. The primary aim is to determine if perindopril improves self-paced gait speed when compared with losartan and HCTZ. The secondary aim is to determine the relative effect of perindopril on secondary outcomes such as: (a) exercise capacity, (b) body mass and composition, and (c) circulating indices of cardiovascular risk. This RCT is expected to identify differential effects of first-line antihypertensive medications when combined with physical exercise thus have potential implications for antihypertensive prescription guidelines for older adults. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03295734.
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Affiliation(s)
- Sara A. Harper
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- Integrative Center for Aging Research, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Liliana C. Baptista
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- Integrative Center for Aging Research, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Lisa M. Roberts
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- Integrative Center for Aging Research, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Sarah J. Wherry
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, United States
| | - Rebecca S. Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, United States
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, United States
| | - Kerry L. Hildreth
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, United States
| | - Regina S. Seay
- Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - P. Hunter Allman
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Christy S. Carter
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- Integrative Center for Aging Research, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Inmaculada Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Wendy M. Kohrt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, United States
| | - Thomas W. Buford
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- Integrative Center for Aging Research, University of Alabama at Birmingham, Birmingham, AL, United States
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23
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Wherry SJ, Swanson CM, Wolfe P, Wellington T, Boxer RS, Schwartz RS, Kohrt WM. Bone Biomarker Response to Walking under Different Thermal Conditions in Older Adults. Med Sci Sports Exerc 2020; 51:1599-1605. [PMID: 31083027 DOI: 10.1249/mss.0000000000001967] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Endurance exercise can cause a decrease in serum ionized calcium (iCa) and increases in parathyroid hormone (PTH) and c-terminal telopeptide of type I collagen (CTX), which may be due to Ca loss in sweat. PURPOSE This study aimed to determine whether exercise in a warm environment exaggerates the decrease in iCa and increases in PTH and CTX compared with a cool environment in older adults. METHODS Twelve women and men 61-78 yr old performed two identical 60-min treadmill bouts at ~75% of maximal heart rate under warm and cool conditions. Serum iCa, PTH, and CTX were measured every 15 min starting 15 min before and continuing for 60 min after exercise. Sweat Ca loss was estimated from sweat volume and sweat Ca concentration. RESULTS Sweat volume was low and variable; there were no differences in sweat volume or Ca concentration between conditions. iCa decreased after 15 min of exercise, and the change was similar in both conditions. Increases in PTH (warm: 16.4, 95% confidence interval [CI] = 6.2, 26.5 pg·mL; cool: 17.3, 95% CI = 8.1, 26.4 pg·mL) and CTX (warm: 0.08, 95% CI = 0.05, 0.11 ng·mL; cool: 0.08, 95% CI = 0.01, 0.16 ng·mL) from before to immediately after exercise were statistically significant and similar between conditions. Adjusting for plasma volume shifts did not change the results. CONCLUSION The increases in PTH and CTX, despite the low sweat volume, suggest that dermal Ca loss is not a major factor in the decrease in iCa and increases in PTH and CTX observed during exercise in older adults.
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Affiliation(s)
- Sarah J Wherry
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Christine M Swanson
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Pamela Wolfe
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Toby Wellington
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Rebecca S Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.,VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO
| | - Robert S Schwartz
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.,VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO
| | - Wendy M Kohrt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.,VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO
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24
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Jones CD, Boxer RS. Home care after elective vascular surgery: still more questions than answers. BMJ Qual Saf 2019; 29:968-970. [PMID: 31796575 DOI: 10.1136/bmjqs-2019-009754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Christine D Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
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25
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Portz JD, Fruhauf C, Bull S, Boxer RS, Bekelman D, Casillas A, Gleason K, Bayliss E. CALL A TEENAGER . . . THAT’S WHAT I DO!: GRANDCHILDREN HELP OLDER ADULTS USE NEW TECHNOLOGIES. Innov Aging 2019. [PMCID: PMC6840230 DOI: 10.1093/geroni/igz038.1205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
As older adults increasingly show interest in technology for their well-being, families will play an important role in promoting the adoption and use of beneficial health technologies. The purpose of this study was to conduct a sub-analysis of data collected from a large-scale qualitative project regarding older adults’ experiences using health information technology. Specifically, the sub-analysis explored older adults’ experiences with technology support from family members to inform strategies for promoting older adult engagement with new health technologies. While the primary analysis of the original study was theoretically driven, this paper reports results from the inductive, open-coding analysis. Twenty-four older patients (≥65 years) with multiple chronic conditions (Charlson Comorbidity Index > 2) participated in a focus group conducted at patients’ primary clinic. While conducting the primary theoretically-driven analysis, coders also utilized an open-coding approach to ensure important ideas not reflected in the theoretical code-book were captured. Open-coding resulted in a primary theme, “family support”, that was furthered categorized by who and how the tech-support was provided. Participants were not specifically asked about family support, yet family assistance and encouragement for technology emerged from every focus group. Participants repeatedly mentioned that they called their grandchildren and adult children for help with technology. Participants also reported that family members experienced difficulty when teaching technology use. Family members struggled to explain simple technology tasks and were frustrated by the slow teaching process. Family support, specifically via grandchildren, may have a key role in the successful adoption and use of emerging health technologies.
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Affiliation(s)
| | | | - Sheana Bull
- University of Colorado, Aurora, Colorado, United States
| | - Rebecca S Boxer
- Kaiser Permanente Institute for Health Research, Aurora, Colorado, United States
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26
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Daddato AE, Drake C, Miller EA, Nadash P, Tyler D, Boxer RS. MANAGING MANAGED CARE: PERSPECTIVES FROM KEY STAKEHOLDERS IN SKILLED NURSING FACILITIES. Innov Aging 2019. [PMCID: PMC6845727 DOI: 10.1093/geroni/igz038.1846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
In recent years, Medicare Advantage (MA) plan enrollment has increased, a trend that is expected to continue. Many skilled nursing facilities (SNFs) rely on MA managed care insurer referrals to maintain their census in a market with high competition for post-acute care patients. This study used semi-structured interviews to describe the relationship between MA plans and SNFs from the perspective of key decision-makers in SNFs. Twenty-three interviews were conducted with key stakeholders from 11 Denver Metropolitan area SNFs. A combined purposive-snowball sampling approach was used to identify and recruit select staff from the participating facilities. Interviews focused on the relationship between MA plans and SNFs, including mechanisms of control, power dynamics, and preferences for MA versus Fee-for-Service (FFS) Medicare patients. Key findings included: 1) challenges SNF staff had navigating MA plans’ case management processes, a key mechanism used by MA plans to influence the behavior of SNF decision-makers; 2) MA plans exercising power over beneficiaries’ length of stay, potentially leading to early discharge and heightened risk for rehospitalization; 3) SNF preference for admitting Medicare FFS over MA patients due to higher rates of Medicare FFS reimbursement and greater control over patient care. SNFs are increasingly reliant on MA plans for patient referrals and revenue. The themes suggest that this growing reliance may place SNFs at odds with MA plans on how best to manage overall patient care. It is therefore important that future research investigate how MA plans’ influence over care affects patient outcomes in SNFs and other post-acute settings.
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Affiliation(s)
- Andrea E Daddato
- University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Cynthia Drake
- Colorado School of Public Health, Aurora, Colorado, United States
| | - Edward A Miller
- University of Massachusetts Boston, Boston, Massachusetts, United States
| | - Pamela Nadash
- University of Massachusetts Boston, Boston, Massachusetts, United States
| | - Denise Tyler
- RTI International, Waltham, Massachusetts, United States
| | - Rebecca S Boxer
- Kaiser Permanente Institute for Health Research, Aurora, Colorado, United States
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27
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Daddato AE, Miller EA, Nadash P, Tyler D, Boxer RS. READMISSION RISK BY INSURANCE TYPE FOR PATIENTS WITH HEART FAILURE IN SKILLED NURSING FACILITIES. Innov Aging 2019. [PMCID: PMC6845660 DOI: 10.1093/geroni/igz038.2395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Heart failure (HF) is a leading cause of potentially preventable hospital readmissions for Medicare beneficiaries from skilled nursing facilities (SNFs). This research seeks to determine if a HF patient’s insurance type (Medicare Fee-for-Service (FFS) vs. Medicare Advantage (MA)) influences their risk for readmission within 30 days of hospital discharge to a SNF. MA beneficiaries receive benefits through managed care plans with restricted networks, but typically expanded benefits. This research is particularly timely in light of CMS’ new penalties under the Protecting Access to Medicare Act (PAMA) directed at SNFs for 30-day rehospitalizations. Outcomes data on readmissions from a randomized controlled trial of HF Disease Management in SNFs conducted from 2014-2017 were used to evaluate the risk of readmission. Patients with HF receiving SNF care were enrolled and followed for 30 days from SNF admission. Patients were recruited from 29 primarily for-profit (93%) SNFs that contracted with an average of 4.07 (±5.48) MA plans. Of the 340 study participants followed, 62% had FFS Medicare coverage (n=212) and 38% had MA (n=128). In total, 23% (n=79) of patients experienced at least one readmission within 30 days of hospital discharge. FFS patients had a higher risk of rehospitalization within 30 days of hospital discharge than MA patients (25% vs. 20%), but the association between insurance type and rehospitalization was not statistically significant (p-value=0.177). Findings suggest that insurance type may be an important risk factor for rehospitalizations for patients with HF from SNF; however, a larger sample will need to confirm this relationship.
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Affiliation(s)
- Andrea E Daddato
- University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Edward A Miller
- University of Massachusetts Boston, Boston, Massachusetts, United States
| | - Pamela Nadash
- University of Massachusetts Boston, Boston, Massachusetts, United States
| | - Denise Tyler
- RTI International, Waltham, Massachusetts, United States
| | - Rebecca S Boxer
- Kaiser Permanente Institute for Health Research, Aurora, Colorado, United States
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28
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Dickman Portz J, Ford K, Bekelman DB, Boxer RS, Kutner JS, Czaja S, Elsbernd K, Bull S. "We're Taking Something So Human and Trying to Digitize": Provider Recommendations for mHealth in Palliative Care. J Palliat Med 2019; 23:240-247. [PMID: 31526220 DOI: 10.1089/jpm.2019.0216] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Mobile health (mHealth) is a promising tool for improving health outcomes. However, the benefits of using mHealth in palliative care are under studied. Objective: As a first step to designing meaningful palliative care-specific mobile applications, this research explored provider perspectives regarding the utility of mHealth in palliative care. Design: A qualitative phenomenological study with semistructured interviews. Setting/Subjects: Providers from multiple disciplines working in palliative care settings at an academic medical center. Results: Thematic analysis resulted in five provider recommendations regarding the utility and design of palliative care-specific mHealth, including (i) thoughtfulness to language, context, and delivery when assessing palliative care needs; (ii) include tools for prognosis and advance care planning; (iii) tailor health and quality-of-life goals; (iv) emphasize supports for family and caregivers; and (v) consider technology abilities of older adults. Conclusions: Palliative care providers are enthusiastic about the use of mHealth to improve care coordination, facilitate communication, enhance symptom monitoring, and improve patient-family support. However, providers have reservations about mobile functionality and depersonalized assessment and care. Providers stress the utility of mHealth to facilitate palliative care rather than replace important multidisciplinary services.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado.,mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kelsey Ford
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado.,Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado
| | - Rebecca S Boxer
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Jean S Kutner
- Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado
| | - Sara Czaja
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York
| | - Kira Elsbernd
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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29
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Drake C, Wald HL, Eber LB, Trojanowski JI, Nearing KA, Boxer RS. Research Priorities in Post-acute and Long-term Care: Results of a Stakeholder Needs Assessment. J Am Med Dir Assoc 2019; 20:911-915. [PMID: 30982714 DOI: 10.1016/j.jamda.2019.02.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/07/2019] [Accepted: 02/18/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Conduct a needs assessment among post-acute and long-term care (PA-LTC) stakeholder groups to identify (1) research topics of highest priority and (2) perspectives on research, including concerns/barriers to conducting research in the PA-LTC setting. DESIGN Mixed methods multistakeholder engagement process. Needs assessment conducted with tailored strategies per stakeholder group: interview, survey, and focus group. SETTING AND PARTICIPANTS Four stakeholder groups-medical directors/providers (n = 89), administrative leadership (n = 5), frontline staff (n = 17), and family members of residents and residents themselves (n = 11)-were recruited from the Colorado PA-LTC community through an academic-community partnership between the University of Colorado and Colorado Medical Directors Association. MAIN OUTCOME(S) Stakeholder perspectives on research and high priority PA-LTC research topics. RESULTS Research priorities common across stakeholder groups included polypharmacy (overuse of medication generally and overuse of antibiotics specifically), care transitions, mental health (including dementia, Alzheimer's disease, behaviors), chronic pain, urinary tract infection, and quality of life issues. Providers specifically prioritized heart failure, Parkinson's, and other chronic illnesses. Administrators and directors of nurses emphasized hospitalizations. Staff prioritized medication/therapy compliance. Families/residents prioritized neurologic disease. Concerns included staff burden, consenting process, privacy, and family involvement. CONCLUSIONS/IMPLICATIONS PA-LTC patients have a lot to offer as participants and decision makers in research, frontline staff are enthusiastic about participation, family members want to be involved, and providers value research findings in their practice but need a more supportive environment to produce and participate in research.
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Affiliation(s)
| | | | | | | | | | - Rebecca S Boxer
- University of Colorado School of Medicine, Aurora, CO; Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
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30
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Gustavson AM, Drake C, Lakin A, Daddato AE, Falvey JR, Capell W, Lum HD, Jones CD, Unroe KT, Towsley GL, Stevens-Lapsley JE, Levy CR, Boxer RS. Conducting Clinical Research in Post-acute and Long-term Nursing Home Care Settings: Regulatory Challenges. J Am Med Dir Assoc 2019; 20:798-803. [PMID: 31248598 PMCID: PMC6703170 DOI: 10.1016/j.jamda.2019.04.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 04/11/2019] [Accepted: 04/20/2019] [Indexed: 11/20/2022]
Abstract
Despite multiple initiatives in post-acute and long-term nursing home care settings (NHs) to improve the quality of care while reducing health care costs, research in NHs can prove challenging. Extensive regulation for both research and NHs is designed to protect a highly vulnerable population but can be a deterrent to conducting research. This article outlines regulatory challenges faced by NHs and researchers, such as protecting resident privacy as well as health information and obtaining informed consent. The article provides lessons learned to help form mutually beneficial partnerships between researchers and NHs to conduct studies that grow and advance NH research initiatives and clinical care.
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Affiliation(s)
- Allison M Gustavson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Cynthia Drake
- Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Alison Lakin
- Colorado Multi-Institutional Review Board (COMIRB), University of Colorado School of Medicine, Aurora, CO
| | - Andrea E Daddato
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, Aurora, CO
| | - Jason R Falvey
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Warren Capell
- Department of Medicine, University of Colorado, Aurora, CO
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, Aurora, CO; Veterans Affairs Geriatric Research, Education and Clinical Center, Aurora, CO
| | | | | | - Gail L Towsley
- University of Utah, College of Nursing, Salt Lake City, UT
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO; Veterans Affairs Geriatric Research, Education and Clinical Center, Aurora, CO
| | - Cari R Levy
- Rocky Mountain Regional Medical Center, Aurora, CO
| | - Rebecca S Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, Aurora, CO; Veterans Affairs Geriatric Research, Education and Clinical Center, Aurora, CO.
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Daddato AE, Dollar B, Lum HD, Burke RE, Boxer RS. Identifying Patient Readmissions: Are Our Data Sources Misleading? J Am Med Dir Assoc 2019; 20:1042-1044. [PMID: 31227472 DOI: 10.1016/j.jamda.2019.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 04/24/2019] [Accepted: 04/30/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND The accuracy of data is vital to identifying hospitalization outcomes for clinical trials. Patient attrition and recall bias affects the validity of patient-reported outcomes, and the growing prevalence of Medicare Advantage (MA) could mean Fee-for-Service (FFS) claims are less reliable for ascertaining hospital utilization. Statewide health information exchanges (HIEs) may be a more complete data source but have not been frequently used for research. DESIGN Secondary analysis comparing identification of readmissions using 3 different acquisition approaches. SETTING Randomized controlled trial of heart failure (HF) disease management in 37 skilled nursing facilities (SNFs). PARTICIPANTS Patients with HF discharged from the hospital to SNF. MEASURES Readmissions up to 60 days post-SNF admission collected by patient self-report, recorded by nursing home (NH) staff during the SNF stay, or recorded in the state HIE. RESULTS Among 657 participants (mean age 79 ± 10 years, 49% with FFS), 295 unique readmissions within 60 days of SNF admission were identified. These readmissions occurred among 221 patients. Twenty percent of all readmissions were found using only patient self-report, 28% were only recorded by NH staff during the SNF stay, and 52% were identified only using the HIE. The readmission rate (first readmission only) based only on patient self-report and direct observation was 18% rather than 34% with the addition of the enhanced HIE method. CONCLUSIONS AND IMPLICATIONS More than one-quarter (34%) of HF patients were rehospitalized within 60 days post SNF admission. Use of a statewide HIE resulted in identifying an additional 153 admissions, 52% of all the readmissions seen in this study. Without use of an HIE, nearly half of readmissions would have been missed as a result of incomplete patient self-report or loss to follow-up. Thus, HIEs serve as an important resource for researchers to ensure accurate outcomes data.
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Affiliation(s)
- Andrea E Daddato
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Blythe Dollar
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Hillary D Lum
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO; Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente, Aurora, CO
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Portz JD, Fruhauf C, Bull S, Boxer RS, Bekelman DB, Casillas A, Gleason K, Bayliss EA. "Call a Teenager… That's What I Do!" - Grandchildren Help Older Adults Use New Technologies: Qualitative Study. JMIR Aging 2019; 2:e13713. [PMID: 31518274 PMCID: PMC6715044 DOI: 10.2196/13713] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/29/2019] [Accepted: 04/13/2019] [Indexed: 11/26/2022] Open
Abstract
Background Although family technical support seems intuitive, there is very little research exploring this topic. Objective The objective of this study was to conduct a subanalysis of data collected from a large-scale qualitative project regarding older adults’ experiences in using health information technology. Specifically, the subanalysis explored older adults’ experiences with technology support from family members to inform strategies for promoting older adults’ engagement with new health technologies. Although the primary analysis of the original study was theoretically driven, this paper reports results from an inductive, open-coding analysis. Methods This is a subanalysis of a major code identified unexpectedly from a qualitative study investigating older adults’ use experience of a widespread health technology, the patient portal. A total of 24 older patients (≥65 years) with multiple chronic conditions (Charlson Comorbidity Index >2) participated in focus groups conducted at the patients’ primary clinic. While conducting the primary theoretically driven analysis, coders utilized an open-coding approach to ensure important ideas not reflected in the theoretical code book were captured. Open coding resulted in 1 code: family support. This subanalysis further categorized family support by who provided tech support, how tech support was offered, and the opinions of older participants about receiving family tech support. Results The participants were not specifically asked about family support, yet themes around family assistance and encouragement for technology emerged from every focus group. Participants repeatedly mentioned that they called their grandchildren and adult children if they needed help with technology. Participants also reported that family members experienced difficulty when teaching technology use. Family members struggled to explain simple technology tasks and were frustrated by the slow teaching process. Conclusions The results suggest that older adults ask their family members, particularly grandchildren, to support them in the use of new technologies. However, family may experience difficulties in providing this support. Older adults will be increasingly expected to use health technologies, and family members may help with tech support. Providers and health systems should consider potential family support and engagement strategies to foster adoption and use among older patients.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, University of Colorado, Aurora, CO, United States.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Christine Fruhauf
- Department of Human Development and Family Studies, College of Health and Human Sciences, Colorado State University, Fort Collins, CO, United States
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado, Aurora, CO, United States
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado, Aurora, CO, United States.,Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs, Denver, CO, United States
| | - Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Kathy Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
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Wherry SJ, Wastney M, Swanson CM, Wellington T, Boxer RS, Weaver CM, Kohrt WM. Oral Calcium Loading Before Exercise Influences PTH and CTX Responses. Med Sci Sports Exerc 2019. [DOI: 10.1249/01.mss.0000563089.30668.d4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Portz JD, Bayliss EA, Bull S, Boxer RS, Bekelman DB, Gleason K, Czaja S. Using the Technology Acceptance Model to Explore User Experience, Intent to Use, and Use Behavior of a Patient Portal Among Older Adults With Multiple Chronic Conditions: Descriptive Qualitative Study. J Med Internet Res 2019; 21:e11604. [PMID: 30958272 PMCID: PMC6475817 DOI: 10.2196/11604] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/21/2018] [Accepted: 01/23/2019] [Indexed: 01/18/2023] Open
Abstract
Background Patient portals offer modern digital tools for older adults with multiple chronic conditions (MCC) to engage in their health management. However, there are barriers to portal adoption among older adults. Understanding portal user interface and user experience (UI and UX) preferences of older adults with MCC may improve the accessibility, acceptability, and adoption of patient portals. Objective The aim of this study was to use the Technology Acceptance Model (TAM) as a framework for qualitatively describing the UI and UX, intent to use, and use behaviors among older patients with MCC. Methods We carried out a qualitative descriptive study of Kaiser Permanente Colorado’s established patient portal, My Health Manager. Older patients (N=24; mean 78.41 (SD 5.4) years) with MCC participated in focus groups. Stratified random sampling was used to maximize age and experience with the portal among participants. The semistructured focus groups used a combination of discussion and think-aloud strategies. A total of 2 coders led the theoretically driven analysis based on the TAM to determine themes related to use behavior, portal usefulness and ease of use, and intent to use. Results Portal users commonly used email, pharmacy, and lab results sections of the portal. Although, generally, the portal was seen to be easy to use, simple, and quick, challenges related to log-ins, UI design (color and font), and specific features were identified. Such challenges inhibited participants’ intent to use the portal entirely or specific features. Participants indicated that the portal improved patient-provider communication, saved time and money, and provided relevant health information. Participants intended to use features that were beneficial to their health management and easy to use. Conclusions Older adults are interested in using patient portals and are already taking advantage of the features available to them. We have the opportunity to better engage older adults in portal use but need to pay close attention to key considerations promoting usefulness and ease of use.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, United States.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States.,Department of Family Medicine, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado, Aurora, CO, United States
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - David B Bekelman
- Division of General Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, United States.,Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs, Denver, CO, United States
| | - Kathy Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Sara Czaja
- Division of Geriatrics, Weill Cornell Medicine, New York, NY, United States.,Center for Research and Education on Aging and Technology Enhancement, University of Miami, Miami, FL, United States
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Jones CD, Jones J, Bowles KH, Flynn L, Masoudi FA, Coleman EA, Levy C, Boxer RS. Quality of Hospital Communication and Patient Preparation for Home Health Care: Results From a Statewide Survey of Home Health Care Nurses and Staff. J Am Med Dir Assoc 2019; 20:487-491. [PMID: 30799224 DOI: 10.1016/j.jamda.2019.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 09/21/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To evaluate the quality of communication between hospitals and home health care (HHC) clinicians and patient preparedness to receive HHC in a statewide sample of HHC nurses and staff. DESIGN A web-based 48-question cross-sectional survey of HHC nurses and staff in Colorado to describe the quality of communication after hospital discharge and patient preparedness to receive HHC from the perspective of HHC nurses and staff. Questions were on a Likert scale, with optional free-text questions. SETTING AND PARTICIPANTS Between January and June 2017, we sent a web-based survey to individuals from the 56 HHC agencies in the Home Care Association of Colorado that indicated willingness to participate. RESULTS We received responses from 50 of 122 individuals (41% individual response rate) representing 14 of 56 HHC agencies (25% agency response rate). Half of the respondents were HHC nurses, the remainder were managers, administrators, or quality assurance clinicians. Among respondents, 60% (n = 30) reported receiving insufficient information to guide patient management in HHC and 44% (n = 22) reported encountering problems related to inadequate patient information. Additional tests recommended by hospital clinicians was the communication domain most frequently identified as insufficient (58%). More than half of respondents (52%) indicated that patient preparation to receive HHC was inadequate, with patient expectations frequently including extended-hours caregiving, housekeeping, and transportation, which are beyond the scope of HHC. Respondents with electronic health record (EHR) access for referring providers were less likely to encounter problems related to a lack of information (27% vs 57% without EHR access, P = .04). Respondents with EHR access were also more likely to have sufficient information about medications and contact isolation. CONCLUSIONS/IMPLICATIONS Communication between hospitals and HHC is suboptimal, and patients are often not prepared to receive HHC. Providing EHR access for HHC clinicians is a promising solution to improve the quality of communication.
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Affiliation(s)
- Christine D Jones
- Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
| | - Jacqueline Jones
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kathryn H Bowles
- School of Nursing, University of Pennsylvania, Philadelphia, PA; Visiting Nurse Service of New York, New York, NY
| | | | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Eric A Coleman
- Division of Health Care Policy and Research, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Cari Levy
- Rocky Mountain Regional Veterans Affairs Medical Center, Denver, CO
| | - Rebecca S Boxer
- Rocky Mountain Regional Veterans Affairs Medical Center, Denver, CO; Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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Jones CD, Jones J, Bowles KH, Schroeder S, Masoudi FA, Coleman EA, Falvey J, Levy CR, Boxer RS. Patient, Caregiver, and Clinician Perspectives on Expectations for Home Healthcare after Discharge: A Qualitative Case Study. J Hosp Med 2019; 14:90-95. [PMID: 30785416 PMCID: PMC6574082 DOI: 10.12788/jhm.3140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients discharged from the hospital with skilled home healthcare (HHC) services have multiple comorbidities, high readmission rates, and multiple care needs. In prior work, HHC nurses described that patients often express expectations for services beyond the scope of skilled HHC. OBJECTIVE The objective of this study is to evaluate and compare expectations for HHC from the patient, caregiver, and HHC perspectives after hospital discharge. DESIGN/PARTICIPANTS This was a descriptive qualitative case study including HHC patients, caregivers, and clinicians. Patients were discharged from an academic medical center between July 2017 and February 2018. RESULTS The sample (N = 27) included 11 HHC patients, eight caregivers, and eight HHC clinicians (five nurses and three physical therapists). Patient mean age was 66 years and the majority were female, white, and had Medicare. We observed main themes of clear and unclear expectations for HHC after discharge. Clear expectations occur when the patient and/or caregiver have expectations for HHC aligned with the services received. Unclear expectations occur when the patient and/or caregiver expectations are uncertain or misaligned with the services received. Patients and caregivers with clear expectations for HHC frequently described prior experiences with skilled HHC or work experience within the healthcare field. In most cases with unclear expectations, the patient and caregiver did not have prior experience with HHC. CONCLUSIONS To improve HHC transitions, we recommend actively engaging both patients and caregivers in the hospital and HHC settings to provide education about HHC services, and assess and address additional care needs.
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Affiliation(s)
- Christine D Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Corresponding Author: Christine D. Jones, MD, MS; E-mail: ; Telephone: 720-848-4289; Twitter: @jones_delong
| | - Jacqueline Jones
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kathryn H Bowles
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York
| | - Shara Schroeder
- College of Liberal Arts and Sciences, Department of Sociology, University of Colorado, Denver, Colorado
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Eric A Coleman
- Division of Health Care Policy and Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jason Falvey
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Veterans Affairs Medical Center, Denver, Colorado
- Yale School of Medicine, New Haven, Connecticut
| | - Cari R Levy
- Division of Health Care Policy and Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Veterans Affairs Medical Center, Denver, Colorado
| | - Rebecca S Boxer
- Veterans Affairs Medical Center, Denver, Colorado
- Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Jones CD, Bowles KH, Richard A, Boxer RS, Masoudi FA. High-Value Home Health Care for Patients With Heart Failure: An Opportunity to Optimize Transitions From Hospital to Home. Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.117.003676. [PMID: 28495675 DOI: 10.1161/circoutcomes.117.003676] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christine D Jones
- From the Hospital Medicine Section, Division of General Internal Medicine (C.D.J.), College of Nursing (A.R.), Division of Geriatric Medicine (R.S.B.), and Division of Cardiology (F.A.M.), University of Colorado Anschutz Medical Campus, Aurora; University of Pennsylvania School of Nursing, Philadelphia (K.H.B.); and Department of Biobehavioral Health Sciences, Visiting Nurse Service of New York, NY (K.H.B.).
| | - Kathryn H Bowles
- From the Hospital Medicine Section, Division of General Internal Medicine (C.D.J.), College of Nursing (A.R.), Division of Geriatric Medicine (R.S.B.), and Division of Cardiology (F.A.M.), University of Colorado Anschutz Medical Campus, Aurora; University of Pennsylvania School of Nursing, Philadelphia (K.H.B.); and Department of Biobehavioral Health Sciences, Visiting Nurse Service of New York, NY (K.H.B.)
| | - Angela Richard
- From the Hospital Medicine Section, Division of General Internal Medicine (C.D.J.), College of Nursing (A.R.), Division of Geriatric Medicine (R.S.B.), and Division of Cardiology (F.A.M.), University of Colorado Anschutz Medical Campus, Aurora; University of Pennsylvania School of Nursing, Philadelphia (K.H.B.); and Department of Biobehavioral Health Sciences, Visiting Nurse Service of New York, NY (K.H.B.)
| | - Rebecca S Boxer
- From the Hospital Medicine Section, Division of General Internal Medicine (C.D.J.), College of Nursing (A.R.), Division of Geriatric Medicine (R.S.B.), and Division of Cardiology (F.A.M.), University of Colorado Anschutz Medical Campus, Aurora; University of Pennsylvania School of Nursing, Philadelphia (K.H.B.); and Department of Biobehavioral Health Sciences, Visiting Nurse Service of New York, NY (K.H.B.)
| | - Frederick A Masoudi
- From the Hospital Medicine Section, Division of General Internal Medicine (C.D.J.), College of Nursing (A.R.), Division of Geriatric Medicine (R.S.B.), and Division of Cardiology (F.A.M.), University of Colorado Anschutz Medical Campus, Aurora; University of Pennsylvania School of Nursing, Philadelphia (K.H.B.); and Department of Biobehavioral Health Sciences, Visiting Nurse Service of New York, NY (K.H.B.)
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Gustavson AM, Boxer RS, Nordon-Craft A, Marcus RL, Daddato A, Stevens-Lapsley JE. Advancing Innovation in Skilled Nursing Facilities through Academic Collaborations. Phys Ther J Policy Adm Leadersh 2018; 18:5-16. [PMID: 35747320 PMCID: PMC9217103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
There is growing recognition that acute hospitalization contributes to marked functional decline in older adult populations. Nearly 20% of all hospitalized older adults in the United States are discharged to skilled nursing facilities (SNFs) to address these functional deficits. However, current approaches to care in SNFs may not adequately restore function, which may contribute to low community discharge rates and high hospital readmission rates. Barriers to rehabilitation innovation in SNFs include management, staff, patient, and researcher-level factors. This clinical commentary builds upon clinical innovation strategies in other health care settings by describing barriers in the context of the SNF environment. Fostering collaboration between academic clinical researchers and SNFs may be the answer to advancing rehabilitation practices and care delivery, thereby improving outcomes in this vulnerable population.
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Affiliation(s)
- Allison M. Gustavson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Rebecca S. Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, Aurora, CO
- Veterans Affairs Geriatric Research, Education and Clinical Center, Denver, CO
| | - Amy Nordon-Craft
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Robin L. Marcus
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
| | - Andrea Daddato
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, Aurora, CO
| | - Jennifer E. Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
- Veterans Affairs Geriatric Research, Education and Clinical Center, Denver, CO
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Kohrt WM, Wherry SJ, Wolfe P, Sherk VD, Wellington T, Swanson CM, Weaver CM, Boxer RS. Maintenance of Serum Ionized Calcium During Exercise Attenuates Parathyroid Hormone and Bone Resorption Responses. J Bone Miner Res 2018; 33:1326-1334. [PMID: 29572961 PMCID: PMC6538281 DOI: 10.1002/jbmr.3428] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/08/2018] [Accepted: 03/15/2018] [Indexed: 01/12/2023]
Abstract
Exercise can cause a decrease in serum ionized calcium (iCa) and increases in parathyroid hormone (PTH) and bone resorption. We used a novel intravenous iCa clamp technique to determine whether preventing a decline in serum iCa during exercise prevents increases in PTH and carboxy-terminal collagen crosslinks (CTX). Eleven cycling-trained men (aged 18 to 45 years) underwent two identical 60-min cycling bouts with infusion of Ca gluconate or saline. Blood sampling for iCa, total calcium (tCa), PTH, CTX, and procollagen type 1 amino-terminal propeptide (P1NP) occurred before, during, and for 4 hours after exercise; results are presented as unadjusted and adjusted for plasma volume shifts (denoted with subscript ADJ). iCa decreased during exercise with saline infusion (p = 0.01 at 60 min) and this was prevented by Ca infusion (interaction, p < 0.007); there were abrupt decreases in Ca content (iCaADJ and tCaADJ ) in the first 15 min of exercise under both conditions. PTH and CTX were increased at the end of exercise (both p < 0.01) on the saline day, and markedly attenuated (-65% and -71%; both p < 0.001) by Ca. CTX remained elevated for 4 hours after exercise on the saline day (p < 0.001), despite the return of PTH to baseline by 1 hour after exercise. P1NP increased in response to exercise (p < 0.001), with no difference between conditions, but the increase in P1NPADJ was not significant. Results for PTHADJ and CTXADJ were similar to unadjusted results. These findings demonstrate that bone resorption is stimulated early in exercise to defend serum iCa. Vascular Ca content decreased early in exercise, but neither the reason why this occurred, nor the fate of Ca, are known. The results suggest that the exercise-induced increase in PTH had an acute catabolic effect on bone. Future research should determine whether the increase in PTH generates an anabolic response that occurs more than 4 hours after exercise. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Wendy M Kohrt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Eastern Colorado Geriatric Research, Education, and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Sarah J Wherry
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Pamela Wolfe
- Department of Preventive Medicine and Biometrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vanessa D Sherk
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Toby Wellington
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christine M Swanson
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Connie M Weaver
- Department of Nutrition Science, College of Health and Human Sciences, Purdue University, West Lafayette, IN, USA
| | - Rebecca S Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Eastern Colorado Geriatric Research, Education, and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO, USA
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Heckman GA, Shamji AK, Ladha R, Stapleton J, Boscart V, Boxer RS, Martin LB, Crutchlow L, McKelvie RS. Heart Failure Management in Nursing Homes: A Scoping Literature Review. Can J Cardiol 2018; 34:871-880. [DOI: 10.1016/j.cjca.2018.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 03/31/2018] [Accepted: 04/08/2018] [Indexed: 10/17/2022] Open
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Wherry SJ, Swanson CM, Wolfe P, Boxer RS, Schwartz RS, Kohrt WM. Calcium, PTH, And CTX Responses to Treadmill Walking During Different Thermal Environments in Older Adults. Med Sci Sports Exerc 2018. [DOI: 10.1249/01.mss.0000538486.01835.4f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Zhu W, Luo L, Jain T, Boxer RS, Cui L, Zhang GQ. DCDS: A Real-time Data Capture and Personalized Decision Support System for Heart Failure Patients in Skilled Nursing Facilities. AMIA Annu Symp Proc 2017; 2016:2100-2109. [PMID: 28269970 PMCID: PMC5333307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Heart disease is the leading cause of death in the United States. Heart failure disease management can improve health outcomes for elderly community dwelling patients with heart failure. This paper describes DCDS, a real-time data capture and personalized decision support system for a Randomized Controlled Trial Investigating the Effect of a Heart Failure Disease Management Program (HF-DMP) in Skilled Nursing Facilities (SNF). SNF is a study funded by the NIH National Heart, Lung, and Blood Institute (NHLBI). The HF-DMP involves proactive weekly monitoring, evaluation, and management, following National HF Guidelines. DCDS collects a wide variety of data including 7 elements considered standard of care for patients with heart failure: documentation of left ventricular function, tracking of weight and symptoms, medication titration, discharge instructions, 7 day follow up appointment post SNF discharge and patient education. We present the design and implementation of DCDS and describe our preliminary testing results.
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Affiliation(s)
- Wei Zhu
- Institute of Biomedical Informatics, University of Kentucky, Lexington, KY; Department of EECS, Case Western Reserve University, Cleveland, OH
| | - Lingyun Luo
- Department of EECS, Case Western Reserve University, Cleveland, OH
| | - Tarun Jain
- Department of EECS, Case Western Reserve University, Cleveland, OH
| | - Rebecca S Boxer
- Divisions of Geriatrics and Cardiology, University of Colorado, Aurora, CO
| | - Licong Cui
- Institute of Biomedical Informatics, University of Kentucky, Lexington, KY
| | - Guo-Qiang Zhang
- Institute of Biomedical Informatics, University of Kentucky, Lexington, KY
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Daddato A, Wald HL, Horney C, Fairclough DL, Leister EC, Coors M, Capell WH, Boxer RS. A randomized trial of heart failure disease management in skilled nursing facilities (SNF Connect): Lessons learned. Clin Trials 2017; 14:308-313. [PMID: 28135830 DOI: 10.1177/1740774517690529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS Conducting clinical trials in skilled nursing facilities is particularly challenging. This manuscript describes facility and patient recruitment challenges and solutions for clinical research in skilled nursing facilities. METHODS Lessons learned from the SNF Connect Trial, a randomized trial of a heart failure disease management versus usual care for patients with heart failure receiving post-acute care in skilled nursing facilities, are discussed. Description of the trial design and barriers to facility and patient recruitment along with regulatory issues are presented. RESULTS The recruitment of Denver-metro skilled nursing facilities was facilitated by key stakeholders of the skilled nursing facilities community. However, there were still a number of barriers to facility recruitment including leadership turnover, varying policies regarding research, fear of litigation and of an increased workload. Engagement of facilities was facilitated by their strong interest in reducing hospital readmissions, marketing potential to hospitals, and heart failure management education for their staff. Recruitment of patients proved difficult and there were few facilitators. Identified patient recruitment challenges included patients being unaware of their heart failure diagnosis, patients overwhelmed with their illness and care, and frequently there was no available proxy for cognitively impaired patients. Flexibility in changing the recruitment approach and targeting skilled nursing facilities with higher rates of admissions helped to overcome some barriers. CONCLUSION Recruitment of skilled nursing facilities and patients in skilled nursing facilities for clinical trials is challenging. Strategies to attract both facilities and patients are warranted. These include aligning study goals with facility incentives and flexible recruitment protocols to work with patients in "transition crisis."
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Affiliation(s)
- Andrea Daddato
- GRECC Denver VA Eastern Colorado Health System and Division of Geriatric Medicine, Department of Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Heidi L Wald
- GRECC Denver VA Eastern Colorado Health System and Division of Geriatric Medicine, Department of Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Carolyn Horney
- GRECC Denver VA Eastern Colorado Health System and Division of Geriatric Medicine, Department of Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Diane L Fairclough
- GRECC Denver VA Eastern Colorado Health System and Division of Geriatric Medicine, Department of Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Erin C Leister
- GRECC Denver VA Eastern Colorado Health System and Division of Geriatric Medicine, Department of Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Marilyn Coors
- GRECC Denver VA Eastern Colorado Health System and Division of Geriatric Medicine, Department of Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Warren H Capell
- GRECC Denver VA Eastern Colorado Health System and Division of Geriatric Medicine, Department of Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Rebecca S Boxer
- GRECC Denver VA Eastern Colorado Health System and Division of Geriatric Medicine, Department of Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
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Orr NM, Boxer RS, Dolansky MA, Allen LA, Forman DE. Skilled Nursing Facility Care for Patients With Heart Failure: Can We Make It "Heart Failure Ready?". J Card Fail 2016; 22:1004-1014. [PMID: 27769909 PMCID: PMC7245613 DOI: 10.1016/j.cardfail.2016.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/06/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
Abstract
Skilled nursing facilities (SNFs) have emerged as an integral component of care for older adults with heart failure (HF). Despite their prominent role, poor clinical outcomes for the medically complex patients with HF managed in SNFs are common. Barriers to providing quality care include poor transitional care during hospital-to-SNF and SNF-to-community discharges, lack of HF training among SNF staff, and a lack of a standardized care process among SNF facilities. Although no evidence-based practice standards have been established, various measures and tools designed to improve HF management in SNFs are being investigated. In this review, we discuss the challenges of HF care in SNFs as well as potential targets and recommendations that can help improve care with respect to transitions, HF management within SNFs, and modifiable factors within facilities. Policy considerations that might help catalyze improvements in SNF-based HF management are also discussed.
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Affiliation(s)
- Nicole M Orr
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts; Post-Acute Cardiology Care, Wellesley, Massachusetts.
| | - Rebecca S Boxer
- Eastern Colorado (Denver) Veterans Association GRECC, Denver, Colorado; University of Colorado School of Medicine, Aurora, Colorado
| | | | - Larry A Allen
- University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel E Forman
- Geriatric Cardiology Section, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Jones CD, Cumbler E, Honigman B, Burke RE, Boxer RS, Levy C, Coleman EA, Wald HL. Hospital to Post-Acute Care Facility Transfers: Identifying Targets for Information Exchange Quality Improvement. J Am Med Dir Assoc 2016; 18:70-73. [PMID: 27815110 DOI: 10.1016/j.jamda.2016.09.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/16/2016] [Accepted: 09/16/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Information exchange is critical to high-quality care transitions from hospitals to post-acute care (PAC) facilities. We conducted a survey to evaluate the completeness and timeliness of information transfer and communication between a tertiary-care academic hospital and its related PAC facilities. METHODS This was a cross-sectional Web-based 36-question survey of 110 PAC clinicians and staff representing 31 PAC facilities conducted between October and December 2013. RESULTS We received responses from 71 of 110 individuals representing 29 of 31 facilities (65% and 94% response rates). We collapsed 4-point Likert responses into dichotomous variables to reflect completeness (sufficient vs insufficient) and timeliness (timely vs not timely) for information transfer and communication. Among respondents, 32% reported insufficient information about discharge medical conditions and management plan, and 83% reported at least occasionally encountering problems directly related to inadequate information from the hospital. Hospital clinician contact information was the most common insufficient domain. With respect to timeliness, 86% of respondents desired receipt of a discharge summary on or before the day of discharge, but only 58% reported receiving the summary within this time frame. Through free-text responses, several participants expressed the need for paper prescriptions for controlled pain medications to be sent with patients at the time of transfer. DISCUSSION Staff and clinicians at PAC facilities perceive substantial deficits in content and timeliness of information exchange between the hospital and facilities. Such deficits are particularly relevant in the context of the increasing prevalence of bundled payments for care across settings as well as forthcoming readmissions penalties for PAC facilities. Targets identified for quality improvement include structuring discharge summary information to include information identified as deficient by respondents, completion of discharge summaries before discharge to PAC facilities, and provision of hard-copy opioid prescriptions at discharge.
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Affiliation(s)
- Christine D Jones
- Hospital Medicine Section, Division of General Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO.
| | - Ethan Cumbler
- Hospital Medicine Section, Division of General Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO
| | - Benjamin Honigman
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, CO
| | - Robert E Burke
- Department of Medicine, VA Eastern Colorado Health Care System, Denver, CO; Division of General Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO
| | - Rebecca S Boxer
- Department of Medicine, VA Eastern Colorado Health Care System, Denver, CO
| | - Cari Levy
- Department of Medicine, VA Eastern Colorado Health Care System, Denver, CO; Division of Health Care Policy and Research, University of Colorado Denver School of Medicine, Aurora, CO
| | - Eric A Coleman
- Division of Health Care Policy and Research, University of Colorado Denver School of Medicine, Aurora, CO
| | - Heidi L Wald
- Division of Health Care Policy and Research; Hospital Medicine Section, Division of General Internal Medicine University of Colorado Denver School of Medicine, Aurora, CO
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Dolansky MA, Capone L, Leister E, Boxer RS. Targeting heart failure rehospitalizations in a skilled nursing facility: A case report. Heart Lung 2016; 45:392-6. [PMID: 27340005 DOI: 10.1016/j.hrtlng.2016.05.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/08/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We report on a skilled nursing facility (SNF) that added designated heart failure (HF) beds and created a patient registry to track the number and reasons for rehospitalization. BACKGROUND Targeting the reduction of rehospitalizations from SNFs is an important goal and patients with HF are particularly vulnerable for rehospitalizations as HF disease management programs in SNFs are rare. METHODS A case study of a local quality improvement initiative. RESULTS The data from the registry revealed, that compared to patients without HF, patients with HF were more often rehospitalized for cardiopulmonary symptoms and less often for infection. In addition, patients with HF were most often rehospitalized during the first 7 days of their SNF stay and if they had a primary hospital discharge diagnosis of HF. CONCLUSION We highlight the benefits of a patient registry to guide future quality improvement initiatives to reduce patient rehospitalization rates.
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Affiliation(s)
| | | | - Erin Leister
- University of Colorado School of Public Health, Department of Biostatistics and Informatics, USA
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Jones CD, Wald HL, Boxer RS, Masoudi FA, Burke RE, Capp R, Coleman EA, Ginde AA. Characteristics Associated with Home Health Care Referrals at Hospital Discharge: Results from the 2012 National Inpatient Sample. Health Serv Res 2016; 52:879-894. [PMID: 27196526 DOI: 10.1111/1475-6773.12504] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To assess patient- and hospital-level factors associated with home health care (HHC) referrals following nonelective U.S. patient hospitalizations in 2012. DATA SOURCE The 2012 National Inpatient Sample (NIS). STUDY DESIGN Retrospective, cross-sectional multivariable logistic regression modeling to assess patient- and hospital-level variables in patient discharges with versus without HHC referrals. DATA COLLECTION Analysis included 1,109,905 discharges in patients ≥65 years with Medicare. PRINCIPAL FINDINGS About 29.2 percent of discharges were referred to HHC, which were more likely with older age, female sex, urban location, low income, longer length of stay, higher severity of illness scores, diagnoses of heart failure or sepsis, and hospital location in New England (referent: Pacific). CONCLUSIONS As health policy changes influence postacute HHC, defining specific diagnoses and regional patterns associated with HHC is a first step to optimize postacute HHC services.
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Affiliation(s)
- Christine D Jones
- Hospital Medicine Section, Division of General Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO
| | - Heidi L Wald
- Hospital Medicine Section, Division of General Internal Medicine, Division of Health Care Policy and Research, University of Colorado Denver School of Medicine, Aurora, CO
| | - Rebecca S Boxer
- Division of Geriatric Medicine, University of Colorado Denver School of Medicine, VA Eastern Colorado Health Care System, Aurora, CO
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Denver School of Medicine, Aurora, CO
| | - Robert E Burke
- Department of Medicine, VA Eastern Colorado Health Care System, Denver, CO.,Division of General Internal Medicine, University of Colorado Denver School of Medicine, Denver, CO
| | - Roberta Capp
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, CO
| | - Eric A Coleman
- Division of Health Care Policy and Research, University of Colorado Denver School of Medicine, Aurora, CO
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, CO
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Wherry SJ, Sherk VD, Wolfe P, Wellington T, Quick J, Boxer RS, Kohrt WM. Maintenance of Serum Ionized Calcium during Exercise Attenuates the Exercise-Related Increase in Bone Resorption. Med Sci Sports Exerc 2016. [DOI: 10.1249/01.mss.0000485926.81509.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Jones CD, Ginde AA, Burke RE, Wald HL, Masoudi FA, Boxer RS. Increasing Home Healthcare Referrals upon Discharge from U.S. Hospitals: 2001-2012. J Am Geriatr Soc 2015; 63:1265-6. [PMID: 26096410 DOI: 10.1111/jgs.13467] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Christine D Jones
- Division of General Internal Medicine, Hospital Medicine Section, University of Colorado at Denver, Denver, Colorado
| | - Adit A Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado at Denver, Denver, Colorado
| | - Robert E Burke
- Veterans Affairs Medical Center, Eastern Colorado Health Care System, Denver, Colorado
| | - Heidi L Wald
- Division of General Internal Medicine, Hospital Medicine Section, University of Colorado at Denver, Denver, Colorado.,Division of Health Care Policy and Research, School of Medicine, University of Colorado at Denver, Denver, Colorado
| | | | - Rebecca S Boxer
- Division of Geriatric Medicine, School of Medicine, University of Colorado Denver, Denver, Colorado
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