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Moreines LT, Brody AA, Murali KP. An Evolutionary Concept Analysis of the "Fighter" in the Intensive Care Unit. J Hosp Palliat Nurs 2024; 26:158-165. [PMID: 38345365 DOI: 10.1097/njh.0000000000001017] [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: 05/08/2024]
Abstract
The purpose of this article was to analyze the concept of "the fighter in the intensive care unit (ICU)" per the scientific literature and the impact this mentality has on care administered in the ICU. A literature review and a concept analysis based on Rodger's evolutionary method were performed to identify surrogate terms, antecedents, attributes, and consequences pertaining to the "fighter" in the ICU. Thirteen articles with a focus on "the fighter" were included in this analysis. There is a strong desire to remain optimistic and maintain high spirits as a coping mechanism in the face of extreme prognostic uncertainty. Themes that emerged from the literature were the need to find inner strength and persist in the face of adversity. The concept of "the fighter in the ICU" can serve as either adaptive or maladaptive coping, depending on the larger clinical picture. Patient experiences in the ICU are fraught with physical and psychological distress. How the patient and family unit cope during this anxiety-provoking time is based on the individual. Maintaining optimism and identifying as a fighter can be healthy ways to adapt to the circumstances. This concept analysis highlights the importance of holistic care and instilling hope particularly as patients may be nearing the end of life.
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Martin JL, Cadogan M, Brody AA, Mitchell MN, Hernandez DE, Mangold M, Alessi CA, Song Y, Chodosh J. Improving Sleep Using Mentored Behavioral and Environmental Restructuring (SLUMBER). J Am Med Dir Assoc 2024; 25:925-931.e3. [PMID: 38493807 PMCID: PMC11065626 DOI: 10.1016/j.jamda.2024.02.003] [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: 08/31/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES To evaluate the impact of a mentoring program to encourage staff-delivered sleep-promoting strategies on sleep, function, depression, and anxiety among skilled nursing facility (SNF) residents. DESIGN Modified stepped-wedge unit-level intervention. SETTING AND PARTICIPANTS Seventy-two residents (mean age 75 ± 15 years; 61.5% female, 41% non-Hispanic white, 35% Black, 20% Hispanic, 3% Asian) of 2 New York City urban SNFs. METHODS Expert mentors provided SNF staff webinars, in-person workshops, and weekly sleep pearls via text messaging. Resident data were collected at baseline, post-intervention (V1), and 3-month follow-up (V2), including wrist actigraphy, resident behavioral observations, Pittsburgh Sleep Quality Index (PSQI), Patient Health Questionnaire-9 (PHQ-9) depression scale, Brief Anxiety and Depression Scale (BADS), Brief Cognitive Assessment Tool (BCAT), and select Minimum Data Set 3.0 (MDS 3.0) measures. Linear mixed models were fit for continuous outcomes and mixed-effects logistic models for binary outcomes. Outcomes were modeled as a function of time. Planned contrasts compared baseline to V1 and V2. RESULTS There was significant improvement in PSQI scores from baseline to V1 (P = .009), and from baseline to V2 (P = .008). Other significant changes between baseline and V1 included decreased depression (PHQ-9) (P = .028), increased daytime observed out of bed (P ≤ .001), and increased daytime observed being awake (P < .001). At V2 (vs baseline) being observed out of bed decreased (P < .001). Daytime sleeping by actigraphy increased from baseline to V1 (P = .004), but not V2. MDS 3.0 activities of daily living and pain showed improvements by the second quarter following implementation of SLUMBER (P's ≤ .034). There were no significant changes in BADS or BCAT between baseline and V1 or V2. CONCLUSIONS AND IMPLICATIONS SNF residents had improvements in sleep quality and depression with intervention, but improvements were not sustained at 3-month follow-up. The COVID-19 pandemic led to premature study termination, so full impacts remain unknown.
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Affiliation(s)
- Jennifer L Martin
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Mary Cadogan
- School of Nursing, University of California, Los Angeles, CA, USA
| | - Abraham A Brody
- Rory Meyers College of Nursing, New York University, New York City, NY, USA; Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA
| | - Michael N Mitchell
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Diana E Hernandez
- Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA
| | - Michael Mangold
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai (Beth Israel), New York City, NY, USA
| | - Cathy A Alessi
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA; School of Nursing, University of California, Los Angeles, CA, USA
| | - Yeonsu Song
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, CA, USA; School of Nursing, University of California, Los Angeles, CA, USA
| | - Joshua Chodosh
- Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA; Medicine Service, VA New York Harbor Healthcare System, New York City, NY, USA.
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Chodosh J, Cadogan M, Brody AA, Mitchell MN, Hernandez DE, Mangold M, Alessi CA, Song Y, Martin JL. Implementation Outcomes for the SLUMBER Sleep Improvement Program in Long-Term Care. J Am Med Dir Assoc 2024; 25:932-938.e1. [PMID: 38493806 PMCID: PMC11065623 DOI: 10.1016/j.jamda.2024.02.004] [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: 08/31/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES To describe the implementation of a mentored staff-delivered sleep program in nursing facilities. DESIGN Modified stepped-wedge unit-level intervention. SETTING AND PARTICIPANTS This program was implemented in 2 New York City nursing facilities, with partial implementation (due to COVID-19) in a third facility. METHODS Expert mentors provided staff webinars, in-person workshops, and weekly sleep pearls via text messaging. We used the integrated Promoting Action on Research Implementation in Health Services (i-PARiHS) framework as a post hoc approach to describe key elements of the SLUMBER implementation. We measured staff participation in unit-level procedures and noted their commentary during unit workshops. RESULTS We completed SLUMBER within 5 units across 2 facilities and held 15 leadership meetings before and during program implementation. Sessions on each unit included 3 virtual webinar presentations and 4 in-person workshops for each nursing shift, held over a period of 3 to 4 months. Staff attendance averaged >3 sessions per individual staff member. Approximately 65% of staff present on each unit participated in any given session. Text messaging was useful for engagement, educational reinforcement, and encouraging attendance. We elevated staff as experts in the care of their residents as a strategy for staff engagement and behavior change and solicited challenging cases from staff during workshops to provide strategies to address resident behavior and encourage adoption when successful. CONCLUSIONS AND IMPLICATIONS Engaging staff, leadership, residents, and family of nursing facilities in implementing a multicomponent sleep quality improvement program is feasible for improving nursing facilities' sleep environment. The program required gaining trust at multiple levels through presence and empathy, and reinforcement mechanisms (primarily text messages). To improve scalability, SLUMBER could evolve from an interdisciplinary investigator-based approach to internal coaches in a train-the-trainer model to effectively and sustainably implement this program to improve sleep quality for facility residents.
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Affiliation(s)
- Joshua Chodosh
- Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA; Medicine Service, VA New York Harbor Healthcare System, New York City, NY, USA.
| | - Mary Cadogan
- School of Nursing, University of California, Los Angeles, CA, USA
| | - Abraham A Brody
- Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA; Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York City, NY, USA
| | - Michael N Mitchell
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Diana E Hernandez
- Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA
| | - Michael Mangold
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai (Beth Israel), New York City, New York, USA
| | - Cathy A Alessi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yeonsu Song
- School of Nursing, University of California, Los Angeles, CA, USA; Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jennifer L Martin
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Zhu W, Tang H, Zhang H, Rajamohan HR, Huang SL, Ma X, Chaudhari A, Madaan D, Almahmoud E, Chopra S, Dodson JA, Brody AA, Masurkar AV, Razavian N. Predicting Risk of Alzheimer's Diseases and Related Dementias with AI Foundation Model on Electronic Health Records. medRxiv 2024:2024.04.26.24306180. [PMID: 38712223 PMCID: PMC11071573 DOI: 10.1101/2024.04.26.24306180] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Early identification of Alzheimer's disease (AD) and AD-related dementias (ADRD) has high clinical significance, both because of the potential to slow decline through initiating FDA-approved therapies and managing modifiable risk factors, and to help persons living with dementia and their families to plan before cognitive loss makes doing so challenging. However, substantial racial and ethnic disparities in early diagnosis currently lead to additional inequities in care, urging accurate and inclusive risk assessment programs. In this study, we trained an artificial intelligence foundation model to represent the electronic health records (EHR) data with a vast cohort of 1.2 million patients within a large health system. Building upon this foundation EHR model, we developed a predictive Transformer model, named TRADE, capable of identifying risks for AD/ADRD and mild cognitive impairment (MCI), by analyzing the past sequential visit records. Amongst individuals 65 and older, our model was able to generate risk predictions for various future timeframes. On the held-out validation set, our model achieved an area under the receiver operating characteristic (AUROC) of 0.772 (95% CI: 0.770, 0.773) for identifying the AD/ADRD/MCI risks in 1 year, and AUROC of 0.735 (95% CI: 0.734, 0.736) in 5 years. The positive predictive values (PPV) in 5 years among individuals with top 1% and 5% highest estimated risks were 39.2% and 27.8%, respectively. These results demonstrate significant improvements upon the current EHR-based AD/ADRD/MCI risk assessment models, paving the way for better prognosis and management of AD/ADRD/MCI at scale.
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Affiliation(s)
- Weicheng Zhu
- NYU, Center for Data Science, New York, NY, 10001, USA
| | - Huanze Tang
- NYU, Center for Data Science, New York, NY, 10001, USA
| | - Hao Zhang
- NYU Grossman School of Medicine, Department of Population Health, New York, NY, 10016, USA
| | | | | | - Xinyue Ma
- NYU, Center for Data Science, New York, NY, 10001, USA
| | | | - Divyam Madaan
- NYU, Courant Institute of Mathematical Sciences, New York, NY, 10001, USA
| | - Elaf Almahmoud
- NYU, Courant Institute of Mathematical Sciences, New York, NY, 10001, USA
| | - Sumit Chopra
- NYU, Courant Institute of Mathematical Sciences, New York, NY, 10001, USA
- NYU Grossman School of Medicine, Department of Radiology, New York, NY, 10016, USA
| | - John A. Dodson
- NYU Grossman School of Medicine, Department of Population Health, New York, NY, 10016, USA
- NYU Grossman School of Medicine, Department of Medicine, New York, NY, 10016, USA
| | - Abraham A. Brody
- NYU Grossman School of Medicine, Department of Medicine, New York, NY, 10016, USA
- NYU Grossman School of Medicine, Rory Meyers College of Nursing, Hartford Institute for Geriatric Nursing, New York, NY, 10016, USA
| | - Arjun V. Masurkar
- NYU Grossman School of Medicine, Department of Neurology, New York, NY, 10016, USA
- NYU Grossman School of Medicine, Department of Neuroscience and Physiology, New York, NY, 10016, USA
- NYU Grossman School of Medicine, Neuroscience Institute, New York, NY, 10016, USA
| | - Narges Razavian
- NYU Grossman School of Medicine, Department of Population Health, New York, NY, 10016, USA
- NYU Grossman School of Medicine, Department of Radiology, New York, NY, 10016, USA
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Jones T, Luth EA, Cleland CM, Brody AA. Race and Ethnicity Are Related to Undesirable Home Health Care Outcomes in Seriously Ill Older Adults. J Am Med Dir Assoc 2024; 25:104983. [PMID: 38604244 DOI: 10.1016/j.jamda.2024.03.003] [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: 11/20/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVES Medicare Home Health Care (HHC) services are integral to the care of homebound seriously ill older adults requiring ongoing specialized medical care. Although disparities in health outcomes are well documented in inpatient and primary care, disparities experienced by historically marginalized racial and ethnic groups underrepresented in HHC are understudied. This study aimed to examine the relationship between individual characteristics and differences in HHC health outcomes for seriously ill older adults. DESIGN Secondary data analysis, repeated measure. SETTING AND PARTICIPANTS Seriously ill older adults who received HHC in 2016 in the HHC Outcome and Assessment Information Set (OASIS). METHODS Start of care and discharge data from the 2016 HCC OASIS were used to examine the relationship between individual characteristics and differences in HHC health outcomes identified by the Centers for Medicare and Medicaid Services as key indicators of quality in HHC, including dyspnea, pain frequency, cognitive functioning, and presence of unhealed pressure ulcer stage II or higher. A generalized ordered logit model with partial proportional odds was used for the ordinal categorical outcomes and a logistic regression was used for the binary dependent variable. RESULTS Findings indicated that of 227,402 seriously ill individuals with an HHC episode in 2016, those from underrepresented racial and ethnic groups had between 14% and 57% higher odds of worse health outcomes compared with non-Hispanic white patients with the exception of pain frequency. CONCLUSIONS AND IMPLICATIONS For people living with serious illness, there are significant differences in Medicare HHC health outcomes when comparing underrepresented racial or ethnic beneficiaries with white counterparts. More research is needed to understand how health care processes such as referral patterns or time to care initiation, and structural factors such as HHC agency quality and neighborhood social deprivation are related to health differences observed in the population.
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Affiliation(s)
- Tessa Jones
- Division of General Internal Medicine and the Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Elizabeth A Luth
- Institute for Health, Health Care Policy, and Aging Research, Department of Family Medicine and Community Health, Robert Wood Johnson Medical School, Rutgers University, Rutgers, NJ, USA
| | - Charles M Cleland
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Abraham A Brody
- HIGN, New York University Rory Meyers College of Nursing, and Division of Geriatric Medicine and Palliative Care, New York University Grossman School of Medicine, New York, NY, USA
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Burgdorf JG, Ornstein KA, Liu B, Leff B, Brody AA, McDonough C, Ritchie CS. Variation in Home Healthcare Use by Dementia Status Among a National Cohort of Older Adults. J Gerontol A Biol Sci Med Sci 2024; 79:glad270. [PMID: 38071603 PMCID: PMC10878244 DOI: 10.1093/gerona/glad270] [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: 07/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Medicare-funded home healthcare (HHC) delivers skilled nursing, therapy, and related services through visits to the patient's home. Nearly one-third (31%) of HHC patients have diagnosed dementia, but little is currently known regarding how HHC utilization and care delivery differ for persons living with dementia (PLwD). METHODS We drew on linked 2012-2018 Health and Retirement Study and Medicare claims for a national cohort of 1 940 community-living older adults. We described differences in HHC admission, length of stay, and referral source by patient dementia status and used weighted, multivariable logistic and negative binomial models to estimate the relationship between dementia and HHC visit type and intensity while adjusting for sociodemographic characteristics, health and functional status, and geographic/community factors. RESULTS PLwD had twice the odds of using HHC during a 2-year observation period, compared to those without dementia (odds ratio [OR]: 2.03; p < .001). They were more likely to be referred to HHC without a preceding hospitalization (49.4% vs 32.1%; p < .001) and incurred a greater number of HHC episodes (1.4 vs 1.0; p < .001) and a longer median HHC length of stay (55.8 days vs 40.0 days; p < .001). Among post-acute HHC patients, PLwD had twice the odds of receiving social work services (unadjusted odds ratio [aOR]: 2.15; p = .008) and 3 times the odds of receiving speech-language pathology services (aOR: 2.92; p = .002). CONCLUSIONS Findings highlight HHC's importance as a care setting for community-living PLwD and indicate the need to identify care delivery patterns associated with positive outcomes for PLwD and design tailored HHC clinical pathways for this patient subpopulation.
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Affiliation(s)
- Julia G Burgdorf
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | - Katherine A Ornstein
- Center for Equity in Aging, The Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Bruce Leff
- The Center for Transformative Geriatric Research, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, New York University Meyers College of Nursing, New York, New York, USA
| | - Catherine McDonough
- Department of Population Health Science and Policy, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Christine S Ritchie
- Mongan Institute for Aging and Serious Illness, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Adeyemi O, Walker L, Bermudez E, Cuthel AM, Zhao N, Siman N, Goldfeld K, Brody AA, Bouillon-Minois JB, DiMaggio C, Chodosh J, Grudzen CR. Emergency Nurses' Perceived Barriers and Solutions to Engaging Patients With Life-Limiting Illnesses in Serious Illness Conversations: A United States Multicenter Mixed-Method Analysis. J Emerg Nurs 2024; 50:225-242. [PMID: 37966418 PMCID: PMC10939973 DOI: 10.1016/j.jen.2023.09.010] [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: 09/22/2022] [Revised: 07/27/2023] [Accepted: 09/06/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION This study aimed to assess emergency nurses' perceived barriers toward engaging patients in serious illness conversations. METHODS Using a mixed-method (quant + QUAL) convergent design, we pooled data on the emergency nurses who underwent the End-of-Life Nursing Education Consortium training across 33 emergency departments. Data were extracted from the End-of-Life Nursing Education Consortium post-training questionnaire, comprising a 5-item survey and 1 open-ended question. Our quantitative analysis employed a cross-sectional design to assess the proportion of emergency nurses who report that they will encounter barriers in engaging seriously ill patients in serious illness conversations in the emergency department. Our qualitative analysis used conceptual content analysis to generate themes and meaning units of the perceived barriers and possible solutions toward having serious illness conversations in the emergency department. RESULTS A total of 2176 emergency nurses responded to the survey. Results from the quantitative analysis showed that 1473 (67.7%) emergency nurses reported that they will encounter barriers while engaging in serious illness conversations. Three thematic barriers-human factors, time constraints, and challenges in the emergency department work environment-emerged from the content analysis. Some of the subthemes included the perceived difficulty of serious illness conversations, delay in daily throughput, and lack of privacy in the emergency department. The potential solutions extracted included the need for continued training, the provision of dedicated emergency nurses to handle serious illness conversations, and the creation of dedicated spaces for serious illness conversations. DISCUSSION Emergency nurses may encounter barriers while engaging in serious illness conversations. Institutional-level policies may be required in creating a palliative care-friendly emergency department work environment.
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Affiliation(s)
- Oluwaseun Adeyemi
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | | | | | - Allison M. Cuthel
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | - Nicole Zhao
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
- Renaissance School of Medicine, Stony Brook University, Stony Brook NY
| | - Nina Siman
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | - Keith Goldfeld
- New York University Grossman School of Medicine, Department of Population Health, New York, New York, USA
| | - Abraham A. Brody
- New York University Rory Meyers College of Nursing, New York, NY, USA; Hartford Institute for Geriatric Nursing, New York, NY, USA; Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jean-Baptiste Bouillon-Minois
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
- Emergency Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Charles DiMaggio
- New York University Grossman School of Medicine, Department of Surgery, New York, New York, USA
| | - Joshua Chodosh
- New York University Grossman School of Medicine, Department of Population Health, New York, New York, USA
- New York University Grossman School of Medicine, Department of Medicine, New York, New York, USA
| | - Corita R. Grudzen
- New York University Grossman School of Medicine, Department of Surgery, New York, New York, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Zhang H, Jethani N, Jones S, Genes N, Major VJ, Jaffe IS, Cardillo AB, Heilenbach N, Ali NF, Bonanni LJ, Clayburn AJ, Khera Z, Sadler EC, Prasad J, Schlacter J, Liu K, Silva B, Montgomery S, Kim EJ, Lester J, Hill TM, Avoricani A, Chervonski E, Davydov J, Small W, Chakravartty E, Grover H, Dodson JA, Brody AA, Aphinyanaphongs Y, Masurkar A, Razavian N. Evaluating Large Language Models in Extracting Cognitive Exam Dates and Scores. medRxiv 2024:2023.07.10.23292373. [PMID: 38405784 PMCID: PMC10888985 DOI: 10.1101/2023.07.10.23292373] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Importance Large language models (LLMs) are crucial for medical tasks. Ensuring their reliability is vital to avoid false results. Our study assesses two state-of-the-art LLMs (ChatGPT and LlaMA-2) for extracting clinical information, focusing on cognitive tests like MMSE and CDR. Objective Evaluate ChatGPT and LlaMA-2 performance in extracting MMSE and CDR scores, including their associated dates. Methods Our data consisted of 135,307 clinical notes (Jan 12th, 2010 to May 24th, 2023) mentioning MMSE, CDR, or MoCA. After applying inclusion criteria 34,465 notes remained, of which 765 underwent ChatGPT (GPT-4) and LlaMA-2, and 22 experts reviewed the responses. ChatGPT successfully extracted MMSE and CDR instances with dates from 742 notes. We used 20 notes for fine-tuning and training the reviewers. The remaining 722 were assigned to reviewers, with 309 each assigned to two reviewers simultaneously. Inter-rater-agreement (Fleiss' Kappa), precision, recall, true/false negative rates, and accuracy were calculated. Our study follows TRIPOD reporting guidelines for model validation. Results For MMSE information extraction, ChatGPT (vs. LlaMA-2) achieved accuracy of 83% (vs. 66.4%), sensitivity of 89.7% (vs. 69.9%), true-negative rates of 96% (vs 60.0%), and precision of 82.7% (vs 62.2%). For CDR the results were lower overall, with accuracy of 87.1% (vs. 74.5%), sensitivity of 84.3% (vs. 39.7%), true-negative rates of 99.8% (98.4%), and precision of 48.3% (vs. 16.1%). We qualitatively evaluated the MMSE errors of ChatGPT and LlaMA-2 on double-reviewed notes. LlaMA-2 errors included 27 cases of total hallucination, 19 cases of reporting other scores instead of MMSE, 25 missed scores, and 23 cases of reporting only the wrong date. In comparison, ChatGPT's errors included only 3 cases of total hallucination, 17 cases of wrong test reported instead of MMSE, and 19 cases of reporting a wrong date. Conclusions In this diagnostic/prognostic study of ChatGPT and LlaMA-2 for extracting cognitive exam dates and scores from clinical notes, ChatGPT exhibited high accuracy, with better performance compared to LlaMA-2. The use of LLMs could benefit dementia research and clinical care, by identifying eligible patients for treatments initialization or clinical trial enrollments. Rigorous evaluation of LLMs is crucial to understanding their capabilities and limitations.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Abraham A Brody
- NYU Rory Meyers College of Nursing, NYU Grossman School of Medicine
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Van Cleave JH, Concert C, Kamberi M, Zahriah E, Most A, Mojica J, Riccobene A, Russo N, Liang E, Hu KS, Jacobson AS, Li Z, Moses LE, Persky MJ, Persky MS, Tran T, Brody AA, Kim A, Egleston BL. A Preliminary Validation of an Optimal Cutpoint in Total Number of Patient-Reported Symptoms in Head and Neck Cancer for Effective Alignment of Clinical Resources with Patients' Symptom Burden. Cancer Care Res Online 2024; 4:e051. [PMID: 38586274 PMCID: PMC10993689 DOI: 10.1097/cr9.0000000000000051] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Background Patients with head and neck cancer (HNC) often experience high symptom burden leading to lower quality of life (QoL). Objective This study aims to conceptually model optimal cutpoint by examining where total number of patient-reported symptoms exceeds patients' coping capacity, leading to a decline in QoL in patients with HNC. Methods Secondary data analysis of 105 individuals with HNC enrolled in a clinical usefulness study of the NYU Electronic Patient Visit Assessment (ePVA)©, a digital patient-reported symptom measure. Patients completed ePVA and European Organization for Research and Treatment of Cancer (EORTC©) QLQ-C30 v3.0. The total number of patient-reported symptoms was the sum of symptoms as identified by the ePVA questionnaire. Analysis of variance (ANOVA) was used to define optimal cutpoint. Results Study participants had a mean age of 61.5, were primarily male (67.6%), and had Stage IV HNC (53.3%). The cutpoint of 10 symptoms was associated with significant decline of QoL (F= 44.8, P<.0001), dividing the population into categories of low symptom burden (< 10 symptoms) and high symptom burden (≥ 10 symptoms). Analyses of EORTC© function subscales supported the validity of 10 symptoms as the optimal cutpoint (Physical: F=28.3, P<.0001; Role: F=21.6, P<.0001; Emotional: F=9.5, P=.003; Social: F=33.1, P<.0001). Conclusions In HNC, defining optimal cutpoints in the total number of patient-reported symptoms is feasible. Implications for Practice Cutpoints in the total number of patient-reported symptoms may identify patients experiencing a high symptom burden from HNC. Foundational Using optimal cutpoints of the total number of patient-reported symptoms may help effectively align clinical resources with patients' symptom burden.
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Affiliation(s)
- Janet H Van Cleave
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Catherine Concert
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Maria Kamberi
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Elise Zahriah
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Allison Most
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Jacqueline Mojica
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Ann Riccobene
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Nora Russo
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Eva Liang
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Kenneth S Hu
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Adam S Jacobson
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Zujun Li
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Lindsey E Moses
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Michael J Persky
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Mark S Persky
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Theresa Tran
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Abraham A Brody
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Arum Kim
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Brian L Egleston
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
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10
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Lassell RKF, Lin SY, Convery K, Fletcher J, Chippendale T, Jones T, Durga A, Galvin JE, Rupper RW, Brody AA. Neuropsychiatric symptoms in people living with dementia receiving home health services. J Am Geriatr Soc 2023; 71:3865-3873. [PMID: 37572061 PMCID: PMC10841370 DOI: 10.1111/jgs.18548] [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: 05/18/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND We sought to describe neuropsychiatric symptoms (NPS) among people living with dementia (PLWD) from diverse racial and ethnic groups receiving home health services while accounting for dementia severity, individual symptom prevalence, and neighborhood disadvantage. METHODS A prospective study using cross-sectional data from n = 192 PLWD receiving skilled home healthcare in New Jersey enrolled in the Dementia Symptom Management at Home Program trial. We prospectively measured symptom prevalence with the Neuropsychiatric Inventory Questionnaire and dementia severity using the Quick Dementia Rating System. A one-way ANOVA determined NPS prevalence by dementia severity (mild, moderate, severe). Fisher's exact tests were used to assess the association of individual symptom prevalence with race and ethnicity and cross tabs to descriptively stratify individual symptom prevalence by dementia severity among groups. A Pearson correlation was performed to determine if a correlation existed among neighborhood disadvantages measured by the Area Deprivation Index (ADI) state decile scores and NPS prevalence and severity. RESULTS Participants identified as non-Hispanic White (50%), non-Hispanic Black (30%), or Hispanic (13%). NPS were prevalent in 97% of participants who experienced 5.4 ± 2.6 symptoms with increased severity (10.8 ± 6.6) and care partner distress (13.8 ± 10.8). NPS increased with dementia severity (p = 0.004) with the greatest difference seen between individuals with mild dementia (4.3 ± 2.3) versus severe dementia (5.9 ± 2.3; p = 0.002). Few differences were found in symptom prevalence by racial and ethnic sub-groups. Nighttime behaviors were higher in non-Hispanic Black (78%), compared with non-Hispanic Whites (46%) with moderate dementia, p = 0.042. State ADI scores were not correlated with the number of NPS reported, or severity. CONCLUSIONS NPS were prevalent and increased with dementia severity with commonalities among racial and ethnic groups with varying levels of neighborhood disadvantage. There is a need for effective methods for improving NPS identification, assessment, and management broadly for homebound PLWD.
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Affiliation(s)
- Rebecca K F Lassell
- Department of Health & Wellness Design, School of Public Health, Indiana University, Bloomington, USA
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Shih-Yin Lin
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Kimberly Convery
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Jason Fletcher
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Tracy Chippendale
- Department of Occupational Therapy, New York University, New York, New York, USA
| | - Tessa Jones
- Silver School of Social Work, New York University, New York, New York, USA
| | - Aditi Durga
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - James E Galvin
- Comprehensive Center for Brain Health, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, New York, USA
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11
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Murali KP, Brody AA, Stimpfel AW. Nurses, Psychological Distress, and Burnout: Is There an App for That? Ann Am Thorac Soc 2023; 20:1404-1405. [PMID: 37772942 PMCID: PMC10559133 DOI: 10.1513/annalsats.202307-629ed] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Affiliation(s)
- Komal Patel Murali
- New York University Rory Meyers College of Nursing, New York, New York; and
| | - Abraham A Brody
- New York University Rory Meyers College of Nursing, New York, New York; and
- New York University Grossman School of Medicine, New York, New York
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12
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Murali KP, Merriman JD, Yu G, Vorderstrasse A, Kelley AS, Brody AA. Complex Care Needs at the End of Life for Seriously Ill Adults With Multiple Chronic Conditions. J Hosp Palliat Nurs 2023; 25:146-155. [PMID: 37040386 PMCID: PMC10175220 DOI: 10.1097/njh.0000000000000946] [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] [Indexed: 04/12/2023]
Abstract
Understanding the complex care needs of seriously ill adults with multiple chronic conditions with and without cancer is critical for the delivery of high-quality serious illness and palliative care at the end of life. The objective of this secondary data analysis of a multisite randomized clinical trial in palliative care was to elucidate the clinical profile and complex care needs of seriously ill adults with multiple chronic conditions and to highlight key differences among those with and without cancer at the end of life. Of the 213 (74.2%) older adults who met criteria for multiple chronic conditions (eg, 2 or more chronic conditions requiring regular care with limitations of daily living), 49% had a diagnosis of cancer. Hospice enrollment was operationalized as an indicator for severity of illness and allowed for the capture of complex care needs of those deemed to be nearing the end of life. Individuals with cancer had complex symptomatology with a higher prevalence of nausea, drowsiness, and poor appetite and end of life and lower hospice enrollment. Individuals with multiple chronic conditions without cancer had lower functional status, greater number of medications, and higher hospice enrollment. The care of seriously ill older adults with multiple chronic conditions requires tailored approaches to improve outcomes and quality of care across health care settings, particularly at the end of life.
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Affiliation(s)
| | | | - Gary Yu
- New York University Rory Meyers College of Nursing
| | | | - Amy S. Kelley
- Icahn School of Medicine at Mount Sinai, Geriatrics and Palliative Medicine
| | - Abraham A. Brody
- New York University Rory Meyers College of Nursing
- New York University Grossman School of Medicine
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13
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David D, Lassell B, Mazor M, Brody AA, Schulman-Green D. "I Have a Lotta Sad Feelin'" - Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living. J Am Med Dir Assoc 2023:S1525-8610(23)00379-1. [PMID: 37169346 DOI: 10.1016/j.jamda.2023.04.002] [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: 10/16/2022] [Revised: 03/01/2023] [Accepted: 04/08/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To investigate mental health needs and barriers to seeking mental health support in Medicaid-funded Assisted Living Facility (M-ALF). DESIGN A multimethod, qualitative-dominant descriptive design using questionnaires and semistructured interviews. SETTING AND PARTICIPANTS The study occurred at a M-ALF in the Bronx, New York. A researcher in residence recruited 13 residents (11 Black or African American, 2 Asian) using purposive sampling. METHODS Demographic data and mental health indicators (depression, anxiety, stress, hopelessness) were measured with questionnaires (Center for Epidemiological Studies Depression Scale, Edmonton Symptom Assessment System, Perceived Stress Scale, Beck Hopelessness Survey) and analyzed with descriptive statistics. Interviews were conducted between June and November 2021, transcribed, and analyzed using conventional content analysis. RESULTS Thirteen residents (mean age: 73.4 years, mean length of stay: 3.5 years; range: 1.0-7.5) completed data collection. Quantitatively indicators of unmet mental health were common. Qualitatively, residents reported barriers to mental health access to address depression, anxiety, and substance use. This was accompanied by concerns surrounding loss of autonomy, mistrust for M-ALF organizational support, isolation and uncertainty about how to receive mental health support. Perspectives were shaped by past experiences with institutional living, serious illness, and being unhoused. Themes and subthemes were (1) mental health need (unmet mental health need, depression, and anxiety and seeking support through non-mental health resources) and (2) barriers to mental health support (dissatisfaction with M-ALF care, perceived threats to autonomy, desire for autonomy that leads to diminished care seeking). CONCLUSION AND IMPLICATIONS Residents of M-ALF have mental health needs for which care is stymied by loss of autonomy, lack of resources, and the M-ALF environment. Residents use unconventional resources to address needs that may be neither efficient nor effective. Novel mental health interventions and processes are needed to improve mental health access and should prioritize residents' desire for autonomy and the unique circumstances of living in M-ALF.
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Affiliation(s)
- Daniel David
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, NY, USA.
| | - Becca Lassell
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Melissa Mazor
- Division of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Dena Schulman-Green
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, NY, USA
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14
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Liddicoat Yamarik R, Chiu LA, Flannery M, Van Allen K, Adeyemi O, Cuthel AM, Brody AA, Goldfeld KS, Schrag D, Grudzen CR. Engagement, Advance Care Planning, and Hospice Use in a Telephonic Nurse-Led Palliative Care Program for Persons Living with Advanced Cancer. Cancers (Basel) 2023; 15:cancers15082310. [PMID: 37190238 DOI: 10.3390/cancers15082310] [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: 02/15/2023] [Revised: 03/31/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
Persons living with advanced cancer have intensive symptoms and psychosocial needs that often result in visits to the Emergency Department (ED). We report on program engagement, advance care planning (ACP), and hospice use for a 6-month longitudinal nurse-led, telephonic palliative care intervention for patients with advanced cancer as part of a larger randomized trial. Patients 50 years and older with metastatic solid tumors were recruited from 18 EDs and randomized to receive nursing calls focused on ACP, symptom management, and care coordination or specialty outpatient palliative care (ClinicialTrials.gov: NCT03325985). One hundred and five (50%) graduated from the 6-month program, 54 (26%) died or enrolled in hospice, 40 (19%) were lost to follow-up, and 19 (9%) withdrew prior to program completion. In a Cox proportional hazard regression, withdrawn subjects were more likely to be white and have a low symptom burden compared to those who did not withdraw. Two hundred eighteen persons living with advanced cancer were enrolled in the nursing arm, and 182 of those (83%) completed some ACP. Of the subjects who died, 43/54 (80%) enrolled in hospice. Our program demonstrated high rates of engagement, ACP, and hospice enrollment. Enrolling subjects with a high symptom burden may result in even greater program engagement.
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Affiliation(s)
| | - Laraine Ann Chiu
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Mara Flannery
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Kaitlyn Van Allen
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Oluwaseun Adeyemi
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Allison M Cuthel
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Abraham A Brody
- Rory Meyers College of Nursing, New York University, New York, NY 10010, USA
- Division of Geriatric Medicine and Palliative Care, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Keith S Goldfeld
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Deborah Schrag
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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15
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Stevens ER, Brody AA, Epps F, Sloan DH, Sherman SE. Using meta-research to foster diverse, equitable, and inclusive collaborative research networks. J Am Geriatr Soc 2023; 71:1028-1033. [PMID: 36585905 PMCID: PMC10089973 DOI: 10.1111/jgs.18217] [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: 09/15/2022] [Revised: 11/18/2022] [Accepted: 12/15/2022] [Indexed: 01/01/2023]
Abstract
Fostering diverse, equitable, and inclusive collaborative research networks is important for advancing the field of aging research. Despite sizeable investment in research consortia and career development programs, there has been only moderate progress toward diversifying the research workforce studying aging. Without critically examining what works and what does not, continuing to place more resources into these same strategies may not result in a substantial improvement in diversity or the creation of collaborative networks. Using meta-research to rigorously evaluate potential strategies to promote diversity and collaboration may yield important insights that can be used to improve upon current efforts. For this reason, we sought to describe meta-research and highlight how its principles can be used to achieve the aging research community's collaboration and diversity goals.
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Affiliation(s)
| | - Abraham A. Brody
- NYU Rory Meyers College of Nursing, Hartford Institute for Geriatric Nursing, New York, NY
| | - Fayron Epps
- Emory University, Nell Hodgson Woodruff School of Nursing, Atlanta, GA
| | | | - Scott E. Sherman
- NYU Grossman School of Medicine, Department of Population Health, New York, NY
- Department of Medicine, VA New York Harbor Healthcare System, New York, NY
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16
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Chodosh J, Mitchell MN, Cadogan M, Brody AA, Alessi CA, Hernandez DE, Mangold M, Martin JL. Improving sleep using mentored behavioral and environmental restructuring (SLUMBER): A randomized stepped-wedge design trial to evaluate a comprehensive sleep intervention in skilled nursing facilities. Contemp Clin Trials 2023; 126:107107. [PMID: 36716989 PMCID: PMC10026593 DOI: 10.1016/j.cct.2023.107107] [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: 09/29/2022] [Revised: 01/04/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Poor sleep is ubiquitous in skilled nursing facilities (SNFs) and is associated with a myriad of negative symptoms. Non-pharmacological interventions can improve sleep, yet sustainability has not been demonstrated. The Improving Sleep Using Mentored Behavioral and Environmental Restructuring (SLUMBER) trial will test whether a staff mentoring approach to address resident sleep issues positively impacts sleep quality and whether improved sleep benefits mood, cognitive performance, and activity engagement for residents living in SNFs. INTERVENTION This is a four-year hybrid type I effectiveness/implementation randomized stepped-wedge trial using a comprehensive sleep improvement program conducted in three urban SNFs. METHODS We will provide SNF staff with sleep promotion strategies over a four-month intervention. Staff will have access to in-person workshops, webinars, weekly sleep pearls via text messaging, environmental data, and expert program mentors. We will consent residents for data collection (at baseline, end of intervention, and three- and six-months post-intervention) including resident observations, questionnaires, and wrist actigraphy (to objectively measure sleep). We will also use selected Minimum Data Set 3.0 (MDS) measures. CONCLUSION SLUMBER uses a unique strategy to iteratively improve sleep interventions through SNF staff buy-in, expert mentoring, and technological supports within a quality improvement framework. As a stepped-wedge trial, the initial SNF units provide opportunities for program improvement in subsequent units, accounting for variation across resident populations at different sites. Protocol limitations include strategies which may require substantial customization for greater spread. A comprehensive staff training program that addresses both sleep quality and related symptoms has the opportunity for considerable dissemination. TRIAL REGISTRATION USGOV Clinical Trials ID: NCT03327324.
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Affiliation(s)
- Joshua Chodosh
- Department of Medicine, New York University Grossman School of Medicine, New York City, NY, United States of America; Medicine Service, VA New York Harbor Healthcare System, New York City, NY, United States of America.
| | - Michael N Mitchell
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CA, United States of America
| | - Mary Cadogan
- School of Nursing, University of California, Los Angeles, CA, United States of America
| | - Abraham A Brody
- Department of Medicine, New York University Grossman School of Medicine, New York City, NY, United States of America; Rory Meyers College of Nursing, New York University, New York City, NY, United States of America
| | - Cathy A Alessi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CA, United States of America; David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Diana E Hernandez
- Department of Medicine, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Michael Mangold
- Department of Medicine, New York University Grossman School of Medicine, New York City, NY, United States of America; Mount Sinai Beth Israel, New York, NY, United States of America
| | - Jennifer L Martin
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CA, United States of America; David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
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17
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David D, Brody AA. One accurate measurement is worth 1000 expert opinions-Assessing quality care in assisted living. J Am Geriatr Soc 2023; 71:1358-1361. [PMID: 36809671 DOI: 10.1111/jgs.18284] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Daniel David
- Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York, New York, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York, New York, USA.,Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, New York, USA
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18
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Ankuda CK, Ornstein KA, Leff B, Rajagopalan S, Kinosian B, Brody AA, Ritchie CS. Defining a taxonomy of Medicare-funded home-based clinical care using claims data. BMC Health Serv Res 2023; 23:120. [PMID: 36747175 PMCID: PMC9900204 DOI: 10.1186/s12913-023-09081-8] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/18/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND As more Americans age in place, it is critical to understand care delivery in the home. However, data on the range of home-based services provided by Medicare is limited. We define a taxonomy of clinical care in the home funded through fee-for-service Medicare and methods to identify receipt of those services. METHODS We analyzed Fee-for-service (FFS) Medicare claims data from a nationally-representative cohort of older adults, the National Health and Aging Trends Study (NHATS), to identify home-based clinical care. We included 6,664 NHATS enrollees age ≥ 70 and living in the community, observed an average of 3 times each on claims-linked NHATS surveys. We examined provider and service type of home-based clinical care to identify a taxonomy of 5 types: home-based medical care (physician, physician assistant, or nurse practitioner visits), home-based podiatry, skilled home health care (SHHC), hospice, and other fee-for-service (FFS) home-based care. We further characterized home-based clinical care by detailed care setting and visit types. RESULTS From 2011-2016, 17.8%-20.8% of FFS Medicare beneficiaries age ≥ 70 received Medicare-funded home-based clinical care. SHHC was the most common service (12.8%-16.1%), followed by other FFS home-based care (5.5%-6.5%), home-based medical care (3.2%-3.9%), and hospice (2.6%-3.0%). Examination of the other-FFS home-based care revealed imaging/diagnostics and laboratory testing to be the most common service. CONCLUSIONS We define a taxonomy of clinical care provided in the home, serving 1 in 5 FFS Medicare beneficiaries. This approach can be used to identify and address research and clinical care gaps in home-based clinical care delivery.
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Affiliation(s)
- Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Subashini Rajagopalan
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce Kinosian
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, NY, USA
- NYU Grossman School of Medicine, New York, NY, USA
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, USA.
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19
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Boafo J, David D, Wu B, Brody AA, Sadarangani T. "The Sun Came Up Because You Got Here…": A Qualitative Exploration of Person-Centered Care Strategies Used by Adult Day Care Centers to Manage Behavioral and Psychological Symptoms of Dementia. J Appl Gerontol 2023; 42:147-159. [PMID: 36165422 DOI: 10.1177/07334648221128283] [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] [Indexed: 01/18/2023] Open
Abstract
In order to reduce care partner strain and support aging in place for people living with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), adult day centers (ADCs) must manage behavioral and psychological symptoms of dementia (BPSD). The purpose of this paper is to identify person-centered care strategies used by center staff to manage BPSD. Six focus groups with center staff (n = 31) were conducted. Data were analyzed using directed content analysis guided by Kitwood's conceptual approach to cultivating personhood in dementia care. Themes were identified and organized within Kitwood's framework. The results demonstrate that staff incorporate evidence-based person-centered approaches to AD/ADRD care that align with Kitwood's principles of comfort, attachment, inclusion, and identity. Staff individualize their approach to people with AD/ADRD within a group setting. They monitor, engage, socially stimulate, and, when needed, de-stimulate them. Centers are flexible social environments with underrecognized expertise managing BPSD using person-centered approaches.
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Affiliation(s)
| | - Daniel David
- 15935New York University College of Nursing, New York, NY, USA
| | - Bei Wu
- 5894New York University, New York, NY, USA
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20
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Murali KP, Yu G, Merriman JD, Vorderstrasse A, Kelley AS, Brody AA. Multiple Chronic Conditions among Seriously Ill Adults Receiving Palliative Care. West J Nurs Res 2023; 45:14-24. [PMID: 34433344 PMCID: PMC9040129 DOI: 10.1177/01939459211041174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The objective of this study was to characterize multiple chronic conditions (MCCs) among seriously ill adults receiving palliative care at the end of life. A latent class analysis was conducted to identify latent subgroups of seriously ill older adults based on a baseline Charlson comorbidity index (CCI) measurement, a measure of comorbidity burden, and mortality risk. The three latent subgroups were: (1) low to moderate CCI with MCC, (2) high CCI with MCC, and (3) high CCI and metastatic cancer. The "low to moderate CCI and MCC" subgroup included older adults with chronic obstructive pulmonary disease (COPD), cardiovascular disease, congestive heart failure, myocardial infarction, dementia, diabetes, and lymphoma. A "high CCI and MCC" subgroup included individuals with severe illness including liver or renal disease among other MCCs. A "high CCI and metastatic cancer" included all participants with metastatic cancer. This study sheds light on the MCC profile of seriously ill adults receiving palliative care.
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Affiliation(s)
| | - Gary Yu
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - John D. Merriman
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | | | - Amy S. Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abraham A. Brody
- Rory Meyers College of Nursing, New York University, New York, NY, USA,Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, NY, USA
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21
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Brody AA, Dorfman E, Caspers CG, Sadarangani TR. What's next for Hospital at Home Programs in the United States: A clarion call for permanent, person-centered solutions. J Am Geriatr Soc 2023; 71:11-14. [PMID: 36321658 PMCID: PMC9963580 DOI: 10.1111/jgs.18089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Abraham A. Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA,Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, New York, USA
| | - Eve Dorfman
- Hospital Administration, NYU Langone Health Long Island, Mineola, New York, USA
| | - Christopher G. Caspers
- Department of Emergency Medicine, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Tina R. Sadarangani
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
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22
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Omeally-Soto S, Zhong J, Boafo J, Wu B, Brody AA, Riffin C, Sadarangani TR. Warning Signs of Acute Infectious Disease-Related Illness in Persons Living With Dementia: Perspectives of Primary Care Providers, Adult Day Service Center Staff, and Family Care Partners. J Psychosoc Nurs Ment Health Serv 2022; 61:35-43. [PMID: 36198122 PMCID: PMC10079777 DOI: 10.3928/02793695-20220929-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
In the current study, we conducted one-on-one interviews with primary care providers (PCPs) and family care partners (FCPs) and held focus groups with interdisciplinary adult day service center (ADSC) staff to understand the perspectives of care providers across community settings regarding early warning signs of acute illnesses in persons living with dementia (PLWD). We used content analysis to analyze qualitative data. Warning signs of acute illnesses in PLWD fell into one of five categories, including new onset changes in (a) physical functions, (b) moods or behaviors (psychological), (c) social interactions, (d) speech, or (e) appearance. FCPs (n = 11) focused on physical changes, whereas ADSC staff (n = 33) emphasized changes in speech and social interactions in addition to the other categories. Although ADSC staff and PCPs (n = 22) focused on changes in functions and moods, each group described these changes differently. ADSC staff possess rich information that can be used to identify acute changes in PLWD and describe a broader range of warning signs compared to PCPs and FCPs. FCPs may benefit from further training in distinguishing between normal disease progression and acute illness. Future research should focus on the implementation of standardized tools across community-based care providers to simplify the identification and reporting of early warning signs in PLWD. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].
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23
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Lassell RKF, Moreines LT, Luebke MR, Bhatti KS, Pain KJ, Brody AA, Luth EA. Hospice interventions for persons living with dementia, family members and clinicians: A systematic review. J Am Geriatr Soc 2022; 70:2134-2145. [PMID: 35441699 PMCID: PMC9283206 DOI: 10.1111/jgs.17802] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 01/12/2022] [Revised: 03/03/2022] [Accepted: 03/11/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hospice care was initially designed for seriously ill individuals with cancer. Thus, the model and clinicians were geared toward caring for this population. Despite the proportion of persons living with dementia (PLWD) receiving hospice care substantially increased over the past 10 years, and their longer lengths of stay, established hospice interventions for this population are scarce. No systematic review has previously evaluated those interventions that do exist. We synthesized hospice intervention studies for PLWD, their families, and hospice professionals by describing the types of interventions, participants, outcomes, and results; assessing study quality; and identifying promising intervention strategies. METHODS A systematic review was conducted using a comprehensive search of five databases through March 2021 and follow-up hand searches. Included studies were peer-reviewed, available in English, and focused on hospice interventions for persons with dementia, and/or care partners, and clinicians. Using pre-determined inclusion and exclusion criteria, data was extracted guided by the Cochrane Checklist, and quality was assessed using a 26-item Consolidated Standards of Reporting Trials (CONSORT) Checklist. RESULTS The search identified 3235 unique studies in total, of which 10 studies met inclusion criteria. The search revealed three types of interventions: clinical education and training, usual care plus care add-on services, and "other" delivered to 707 participants (mostly clinicians). Five studies included underrepresented racial and ethnic groups. Outcomes measured knowledge and skills, psychosocial and health outcomes, feasibility, and acceptability, with significant improvements in six studies. Study quality was reflective of early-stage research with clinical education and training strategies showing deliberate progression towards real-world efficacy testing. IMPLICATIONS Hospice interventions for PLWD are sparse and in early-phase research. More research is needed with rigorous designs, diverse samples, and outcomes considering the concordance of care.
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Affiliation(s)
- Rebecca K F Lassell
- Rory Meyers College of Nursing, Hartford Institute for Geriatric Nursing, New York University, New York, New York, USA
| | - Laura T Moreines
- Rory Meyers College of Nursing, Hartford Institute for Geriatric Nursing, New York University, New York, New York, USA
| | - Matthew R Luebke
- Department of Human Development, Cornell University, Ithaca, New York, USA
| | - Karandeep S Bhatti
- Neurology Department, Cooper University Hospital, Camden, New Jersey, USA
| | - Kevin J Pain
- Weill Cornell Medicine, Samuel J. Wood Library and C. V. Starr Biomedical Information Center, New York, New York, USA
| | - Abraham A Brody
- Rory Meyers College of Nursing, Hartford Institute for Geriatric Nursing, New York University, New York, New York, USA.,Grossman School of Medicine, Division of Geriatrics and Palliative Care, New York University, New York, New York, USA
| | - Elizabeth A Luth
- Institute for Health, Healthcare Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey, USA.,Department of Family Medicine and Community Health, Rutgers University, New Brunswick, New Jersey, USA
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24
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Yamarik RL, Tan A, Brody AA, Curtis J, Chiu L, Bouillon-Minois JB, Grudzen CR. Nurse-Led Telephonic Palliative Care: A Case-Based Series of a Novel Model of Palliative Care Delivery. J Hosp Palliat Nurs 2022; 24:E3-E9. [PMID: 35149656 DOI: 10.1097/njh.0000000000000850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Americans near the end of life experience high rates of nonbeneficial, burdensome, and preventable hospital-based care. If patients' goals of care are unknown or unclear, they have higher rates of hospitalization at the end of life. The demand for palliative care has grown exponentially because of its impact on quality of life, symptom burden, and resource use, requiring the development of new palliative care models. Nurses' holistic outlook and patient-centered focus make them ideal to deliver telephonic palliative care. This article discusses 4 cases delivered by a nurse-led telephonic palliative care program, a part of the Emergency Medicine Palliative Care Access project, which is a randomized controlled trial comparing outpatient palliative care with nurse-led telephonic case management after an emergency department visit. Telephonic nurses discuss patients' goals, fears, hopes, and concerns regarding their illness and its trajectory that inform decisions for future interventions and treatments. In addition, they share this information with the patients' surrogate decision-makers and clinicians to facilitate care coordination and symptom management. For seriously ill patients, nurses' abilities and expertise, as well as the difficulties of providing care through in-person models of palliative care delivery, make a nurse-led telephonic model an optimal option.
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25
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Schneider C, Bristol A, Ford A, Lin SY, Brody AA, Stimpfel AW. A Pilot Observational Exploratory Study of Well-Being in Hospice Interdisciplinary Team Members. Am J Hosp Palliat Care 2022; 39:264-269. [PMID: 35164534 DOI: 10.1177/10499091211023480] [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] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Well-being and turnover intent represent key aspects to the promotion of a healthy workforce. Alarming levels of burnout and low levels of well-being have been documented in health professionals across care settings. Not only do high levels of burnout, low well-being and high turnover affect health professionals, but they are associated with poor patient care. However, limited research has investigated this topic specifically in hospice interdisciplinary team (IDT) members, nurses, chaplains, social workers. Thus, the purpose of this study was to explore hospice IDT members' well-being, and turnover intent. METHODS This observational, pilot study used quantitative surveys to examine the well-being, and turnover intention at baseline and at 3 months. Twenty-five hospice IDT members at one site participated. RESULTS Paired t-tests and percent change demonstrated significant decreases in compassion satisfaction (44.5 vs. 42.1, p = 0.04) and secondary traumatic stress score (18.5 vs. 13.3, p = 0.0001) and a significant increase in burnout score (17.6 vs. 20.5, p = 0.03) from baseline to follow up. Employee turnover slightly decreased from baseline to follow-up. CONCLUSIONS In this pilot study, hospice IDT members had low levels of well-being at baseline that worsened over 3-months indicating a higher potential risk for burnout. Moreover, given the COVID-19 pandemic, this may be an ominous sign of what lies ahead for hospice providers regarding turnover, leading to significant long-term staffing problems in the field. If these results hold true in a larger sample, it could necessitate developing and testing further strategies to ensure a healthy and stable workforce.
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Affiliation(s)
- Catherine Schneider
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, NY, USA
| | - Alycia Bristol
- College of Nursing, University of Utah, Salt Lake City, UT, USA
| | - Ariel Ford
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, NY, USA
| | - Shih-Yin Lin
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, NY, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, NY, USA
| | - Amy Witkoski Stimpfel
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, NY, USA
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26
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Brody AA, Convery KA, Kline DM, Fink RM, Fischer SM. Transitioning to Remote Recruitment and Intervention: A Tale of Two Palliative Care Research Studies Enrolling Underserved Populations During COVID-19. J Pain Symptom Manage 2022; 63:151-159. [PMID: 34161811 PMCID: PMC8685301 DOI: 10.1016/j.jpainsymman.2021.06.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 04/07/2021] [Revised: 06/11/2021] [Accepted: 06/16/2021] [Indexed: 12/25/2022]
Abstract
CONTEXT During the COVID-19 pandemic, community-based research studies experienced prolonged shutdowns unless able to pivot to remote study procedures. OBJECTIVES To describe the revision of two National Institutes of Health funded community-based palliative-focused clinical trials serving underserved populations to accommodate remote subject enrollment and examine its impact. METHODS Transitioning to remote processes required multiple protocol and procedural changes including: altering informed consent processes; reducing the number of surveys administered; adding internet access as an inclusion criterion. To understand technological challenges, a screening tool was developed for one study to identify potentially eligible subjects' technology abilities and accessibility. RESULTS Subjects' limited access to the internet and internet-enabled devices and discomfort with technology led to changes in recruitment patterns. Lack of familiarity with technology increased the amount of time it took research team members and subjects to connect remotely. Patients with significant cognitive and/or sensory deficits were at higher risk of experiencing fatigue during remote study visits leading to streamlining of data collection. A researcher-developed technology screening tool found that potential subjects were not comfortable with videoconferencing through Zoom expressing a preference for phone visits. Reduced travel time made scheduling remote study visits more efficient. CONCLUSION Future community- and home-based palliative care trials must consider the best way to utilize remote recruitment, enrollment, and data collection processes to increase efficiency and reduce costs. Researchers should consider technology accessibility and train staff to ensure the greatest possible opportunity to recruit underserved populations who have traditionally been underrepresented in research studies.
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Affiliation(s)
- Abraham A Brody
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, Aurora, Colorado, USA
| | - Kimberly A Convery
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, Aurora, Colorado, USA
| | - Danielle M Kline
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Regina M Fink
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, School of Medicine and College of Nursing, Aurora, Colorado, USA.
| | - Stacy M Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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David D, Lin SY, Groom LL, Ford A, Brody AA. Aliviado Mobile App for Hospice Providers: A Usability Study. J Pain Symptom Manage 2022; 63:e37-e45. [PMID: 34389414 PMCID: PMC8766865 DOI: 10.1016/j.jpainsymman.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 04/23/2021] [Revised: 07/13/2021] [Accepted: 07/22/2021] [Indexed: 01/03/2023]
Abstract
CONTEXT Evaluation of usability and mobile health content is critical for ensuring effective implementation of technology utilizing interventions tailored to the needs of hospice care providers for people living with dementia in community-based settings. OBJECTIVES To evaluate the usability, content, and "readiness to launch" of the Aliviado mobile health app for interdisciplinary team members participating in the Hospice Advanced Dementia Symptom Management and Quality of Life. METHODS Usability of the Aliviado app was assessed in 86 respondents with an adapted IBM Computer Usability Satisfaction Questionnaire following Hospice Advanced Dementia Symptom Management and Quality of Life training and implementation of the mobile app. RESULTS More than half of users receiving training employed the mobile app in practice. Users reported use as: Daily-6.3%, Weekly-39.6%, monthly-54.2%. The highest measured attributes were usefulness, value, and effectiveness. Over 90% deemed the app "ready to launch" with no or minimal problems. CONCLUSION This study shows that a newly-developed mobile app is usable and can be successfully adopted for care of people living with dementia.
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Affiliation(s)
- Daniel David
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA.
| | - Shih-Yin Lin
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Lisa L Groom
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Ariel Ford
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
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28
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Zhong J, Boafo J, Brody AA, Wu B, Sadarangani AT. A qualitative analysis of communication workflows between adult day service centers and primary care providers. J Am Med Inform Assoc 2021; 29:882-890. [PMID: 34964467 PMCID: PMC9006686 DOI: 10.1093/jamia/ocab284] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/05/2021] [Accepted: 12/17/2021] [Indexed: 12/05/2022] Open
Abstract
Objectives Our study documented communication workflows across adult day care centers (ADCs) and primary care providers (PCPs) around complex needs of persons living with dementia (PLWD). We also identified barriers and facilitators to productive communication in clinical decision support and clinical information systems. Materials and Methods We conducted 6 focus groups with ADC staff (N = 33) and individual semistructured interviews with PCPs (N = 22) in California. The eHealth Enhanced Chronic Care Model was used to frame the directed qualitative content analysis. Results Our results captured cumbersome and ineffective workflows currently used to exchange information across PCPs and ADCs. Stakeholders characterized current communication as (1) infrequent, (2) delayed, (3) incomplete, (4) unreliable, (5) irrelevant, and (6) generic. Conversely, communication that was bidirectional, relevant, succinct, and interdisciplinary was needed to elevate the standard of care for PLWD. Discussion and Conclusion ADCs possess a wealth of information that can support clinical decision-making across community-based providers involved in the care of PLWD, especially PCPs. However, effective information exchange is mired by complicated workflows that rely on antiquated technologies (eg, facsimile) and standard templates. Current information exchange largely focuses on satisfying regulatory guidelines rather than supporting clinical decision-making. Integrating community-based services into the health care continuum is a necessary step in elevating the standard of care for PLWD. In the absence of interoperable electronic health records, which may not be financially viable for ADCs, other options, such as mobile health, should be explored to facilitate productive information exchange of personalized relevant information.
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Affiliation(s)
- Jie Zhong
- New York University Rory Meyers College of Nursing, New York City, New York, USA
| | - Jonelle Boafo
- New York University Rory Meyers College of Nursing, New York City, New York, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York City, New York, USA.,Division of Geriatric Medicine and Palliative Care, Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - Bei Wu
- Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York City, New York, USA
| | - And Tina Sadarangani
- Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York City, New York, USA
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Gettel CJ, Voils CI, Bristol AA, Richardson LD, Hogan TM, Brody AA, Gladney MN, Suyama J, Ragsdale LC, Binkley CL, Morano CL, Seidenfeld J, Hammouda N, Ko KJ, Hwang U, Hastings SN, Bellolio MF, Biese K, Binkley C, Bott N, Brody A, Carpenter C, Clark S, Dresden MS, Forrester S, Gerson L, Gettel C, Goldberg E, Greenberg A, Hammouda N, Han J, Hastings SN, Hogan T, Hung W, Hwang U, Kayser J, Kennedy M, Ko K, Lesser A, Linton E, Liu S, Malsch A, Matlock D, McFarland F, Melady D, Morano C, Morrow‐Howell N, Nassisi D, Nerbonne L, Nyamu S, Ohuabunwa U, Platts‐Mills T, Ragsdale L, Richardson L, Ringer T, Rosen A, Rosenberg M, Shah M, Skains R, Skees S, Souffront K, Stabler L, Sullivan C, Suyama J, Vargas S, Camille Vaughan E, Voils C, Wei D, Wexler N. Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement. Acad Emerg Med 2021; 28:1430-1439. [PMID: 34328674 DOI: 10.1111/acem.14360] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 04/29/2021] [Revised: 07/05/2021] [Accepted: 07/20/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions. METHODS GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research. RESULTS Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research. CONCLUSIONS ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
- National Clinician Scholars Program Department of Internal Medicine Yale School of Medicine New Haven Connecticut USA
| | - Corrine I. Voils
- William S. Middleton Memorial Veterans Hospital Madison Wisconsin USA
- Department of Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
| | | | - Lynne D. Richardson
- Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York New York USA
- Department of Population Health Science & Policy Icahn School of Medicine at Mount Sinai New York New York USA
- Institute for Health Equity Research Icahn School of Medicine at Mount Sinai New York New York USA
| | - Teresita M. Hogan
- Department of Medicine Section of Emergency Medicine The University of Chicago School of Medicine Chicago Illinois USA
| | - Abraham A. Brody
- Hartford Institute for Geriatric Nursing New York University Rory Meyers College of Nursing New York New York USA
| | - Micaela N. Gladney
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham VA Health Care System Durham North Carolina USA
| | - Joe Suyama
- Department of Emergency Medicine University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Luna C. Ragsdale
- Department of Surgery Division of Emergency Medicine Duke University School of Medicine Durham North Carolina USA
- Department of Emergency Medicine Durham VA Health Care System Durham North Carolina USA
| | - Christine L. Binkley
- Department of Emergency Medicine University of North Carolina School of Medicine Chapel Hill North Carolina USA
| | - Carmen L. Morano
- School of Social Welfare University at AlbanyState University of New York Albany New York USA
| | - Justine Seidenfeld
- Department of Surgery Division of Emergency Medicine Duke University School of Medicine Durham North Carolina USA
| | - Nada Hammouda
- Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York New York USA
| | - Kelly J. Ko
- West Health Institute La Jolla California USA
| | - Ula Hwang
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
- Geriatrics Research, Education, and Clinical Center James J. Peters VAMC Bronx New York USA
| | - Susan N. Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham VA Health Care System Durham North Carolina USA
- Department of Medicine Duke University School of Medicine Durham NC USA
- Geriatric Research, Education, and Clinical Center Durham VA Health Care System Durham North Carolina USA
- Center for the Study of Human Aging and Development Duke University School of Medicine Durham North Carolina USA
- Department of Population Health Sciences Duke University School of Medicine Durham North Carolina USA
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Ben-Zacharia AB, Janal MN, Brody AA, Wolinsky J, Lublin F, Cutter G. The Effect of Body Mass Index on Brain Volume and Cognitive Function in Relapsing-Remitting Multiple sclerosis: A CombiRx Secondary Analysis. J Cent Nerv Syst Dis 2021; 13:11795735211042173. [PMID: 34759712 PMCID: PMC8573693 DOI: 10.1177/11795735211042173] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/07/2021] [Indexed: 11/22/2022] Open
Abstract
Background Multiple sclerosis (MS) is an autoimmune disease leading to physical, emotional and cognitive disability. High body mass index (BMI) may impact cognitive function and brain volume in MS. Yet, there is paucity of evidence addressing the impact of BMI on cognitive function and brain volume in MS. Objectives The purpose of this study was to examine the effects of BMI on normal appearing brain volume and cognitive function in patients with relapsing–remitting MS. Methods A secondary data analysis of the NIH CombiRx study was conducted. Multivariate regression and mixed model analyses were executed to analyze the effect of BMI on brain volume and cognitive function. Results The mean baseline age of the 768 participants was 38.2(SD = 9.4) years. 73% were female and 88.8% were Caucasian. The mean BMI was 28.8 kg/m2(SD = 6.7). The multivariate regression and mixed model analyses failed to show a clinical effect of BMI on brain volume and cognitive function. Conclusion BMI did not show an effect on cognitive function and brain volume among MS patients. Although there is increased interest in the effects of modifiable factors on the course of MS, the effects of BMI on brain volume and cognitive function are debatable and warrant further research. ClinicalTrials.gov NCT00211887
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Affiliation(s)
- Aliza Bitton Ben-Zacharia
- Mount Sinai Hospital, New York, NY, USA.,Bellevue School of Nursing, Hunter College, New York, NY, USA
| | - Malvin N Janal
- Department of Epidemiology and Health Promotion, NYU College of Dentistry, New York, NY, USA
| | | | - Jerry Wolinsky
- McGovern Medical School, University of Texas, Huston, TX, USA
| | - Fred Lublin
- Department of Medicine, Mount Sinai Icahn School of Medicine, New York, NY, USA
| | - Gary Cutter
- School of Public Health, UAB, Birmingham, AL, USA
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31
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Murali KP, Yu G, Merriman JD, Vorderstrasse A, Kelley AS, Brody AA. Latent Class Analysis of Symptom Burden Among Seriously Ill Adults at the End of Life. Nurs Res 2021; 70:443-454. [PMID: 34393192 PMCID: PMC8563402 DOI: 10.1097/nnr.0000000000000549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Serious illness is characterized by high symptom burden that negatively affects quality of life (QOL). Although palliative care research has highlighted symptom burden in seriously ill adults with cancer, symptom burden among those with noncancer serious illness and multiple chronic conditions has been understudied. Latent class analysis is a statistical method that can be used to better understand the relationship between severity of symptom burden and covariates, such as the presence of multiple chronic conditions. Although latent class analysis has been used to highlight subgroups of seriously ill adults with cancer based on symptom clusters, none have incorporated multiple chronic conditions. OBJECTIVES The objectives of this study were to (a) describe the demographic and baseline characteristics of seriously ill adults at the end of life in a palliative care cohort, (b) identify latent subgroups of seriously ill individuals based on severity of symptom burden, and (c) examine variables associated with latent subgroup membership, such as QOL, functional status, and the presence of multiple chronic conditions. METHODS A secondary data analysis of a palliative care clinical trial was conducted. The latent class analysis was based on the Edmonton Symptom Assessment System, which measures nine symptoms on a scale of 0-10 (e.g., pain, fatigue, nausea, depression, anxiousness, drowsiness, appetite, well-being, and shortness of breath). Clinically significant cut-points for symptom severity were used to categorize each symptom item in addition to a categorized total score. RESULTS Three latent subgroups were identified (e.g., low, moderate, and high symptom burden). Lower overall QOL was associated with membership in the moderate and high symptom burden subgroups. Multiple chronic conditions were associated with statistically significant membership in the high symptom burden latent subgroup. Older adults between 65 and 74 years had a lower likelihood of moderate or high symptom burden subgroup membership compared to the low symptom burden class. DISCUSSION Lower QOL was associated with high symptom burden. Multiple chronic conditions were associated with high symptom burden, which underlines the clinical complexity of serious illness. Palliative care at the end of life for seriously ill adults with high symptom burden must account for the presence of multiple chronic conditions.
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Jones T, Luth EA, Lin SY, Brody AA. Advance Care Planning, Palliative Care, and End-of-life Care Interventions for Racial and Ethnic Underrepresented Groups: A Systematic Review. J Pain Symptom Manage 2021; 62:e248-e260. [PMID: 33984460 PMCID: PMC8419069 DOI: 10.1016/j.jpainsymman.2021.04.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [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: 02/05/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 11/25/2022]
Abstract
CONTEXT Persons from underrepresented racial and ethnic groups experience disparities in access to and quality of palliative and end-of-life care. OBJECTIVES To summarize and evaluate existing palliative and end-of-life care interventions that aim to improve outcomes for racial and ethnic underrepresented populations in the United States. METHODS We conducted a systematic review of the literature in the English language from four databases through January 2020. Peer-reviewed studies that implemented interventions on palliative care, advance care planning, or end-of-life care were considered eligible. Data were extracted from 16 articles using pre-specified inclusion and exclusion criteria. Quality was appraised using the modified Downs and Black tool for assessing risk of bias in quantitative studies. RESULTS Five studies were randomized controlled trials, and the remainder were quasi-experiments. Six studies targeted Latino/Hispanic Americans, five African Americans, and five, Asian or Pacific Islander Americans. The two randomized control trials reviewed and rated "very high" quality, found educational interventions to have significant positive effects on advance care planning and advance directive completion and engagement for underrepresented racial or ethnic groups. CONCLUSION The effectiveness of advance care planning, end-of-life, and palliative care interventions in improving outcomes for underrepresented racial and ethnic populations remains uncertain. Randomized controlled trials and educational interventions indicate that interventions targeting underrepresented groups can have significant and positive effects on advance directives and/or advance care planning-related outcomes. More high-quality intervention studies that address racial and ethnic health disparities in palliative care are needed, particularly those that address systemic racism and other complex multilevel factors that influence disparities in health.
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Affiliation(s)
- Tessa Jones
- New York University, New York, New York, USA.
| | | | - Shih-Yin Lin
- NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, USA
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33
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Gorbenko K, Franzosa E, Masse S, Brody AA, Sheehan O, Kinosian B, Ritchie CS, Leff B, Ripp J, Ornstein KA, Federman AD. "I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York. Home Health Care Serv Q 2021; 40:1-15. [PMID: 34301160 PMCID: PMC8783921 DOI: 10.1080/01621424.2021.1935383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Indexed: 01/25/2023]
Abstract
Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.
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Affiliation(s)
- Ksenia Gorbenko
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute of Health Care Delivery Science, Mount Sinai Health System, New York, New York, USA
| | - Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, New York, USA
| | - Sybil Masse
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Abraham A Brody
- Hartford Institute of Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Orla Sheehan
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bruce Kinosian
- Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Geriatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatrics, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Ripp
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Katherine A. Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex D. Federman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Federman AD, Leff B, Brody AA, Lubetsky S, Siu AL, Ritchie CS, Ornstein KA. Disruptions in Care and Support for Homebound Adults in Home-Based Primary Care in New York City During the COVID-19 Pandemic. Home Healthc Now 2021; 39:211-214. [PMID: 34190705 PMCID: PMC8345896 DOI: 10.1097/nhh.0000000000000983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Homebound older adults are a highly vulnerable population, yet little is known about their experiences with healthcare during the COVID-19 pandemic. We interviewed patients in home-based primary care (HBPC) in New York City by telephone in May and June of 2020. Interviews covered social supports, household activities, self-care, and medical care, and asked participants to compare current with prepandemic experiences. Among 70 participants, 37% were Black and 32% were Hispanic. Disruptions in the home included greater difficulty accessing paid caregivers (13.9%) and food (35.3%) than before the pandemic, and unaddressed household chores (laundry, 81.4%; food preparation, 11.4%). Black study participants were more likely than White and Hispanic participants to report disruptions in accessing medical care (13 [50.0%] vs. 3 [14.3%] vs. 6 [27.3%], respectively, p = 0.02), as well as food preparation and medication taking. Black patients in HBPC are at risk of disparities in healthcare and social support during the COVID-19 pandemic.
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Franzosa E, Gorbenko K, Brody AA, Leff B, Ritchie CS, Kinosian B, Sheehan OC, Federman AD, Ornstein KA. "There Is Something Very Personal About Seeing Someone's Face": Provider Perceptions of Video Visits in Home-Based Primary Care During COVID-19. J Appl Gerontol 2021; 40:1417-1424. [PMID: 34210200 DOI: 10.1177/07334648211028393] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The rapid deployment of video visits during COVID-19 may have posed unique challenges for home-based primary care (HBPC) practices due to their hands-on model of care and older adult population. This qualitative study examined provider perceptions of video visits during the first wave of the COVID-19 crisis in New York City (NYC) through interviews with HBPC clinical/medical directors, program managers, nurse practitioners/nurse managers, and social work managers (n = 13) at six NYC-area practices. Providers reported a combination of commercial (health system-supported) and consumer (e.g., FaceTime) technological platforms was essential. Video visit benefits included triaging patient needs, collecting patient information, and increasing scheduling capacity. Barriers included cognitive and sensory abilities, technology access, reliance on caregivers and aides, addressing sensitive topics, and incomplete exams. Effectively integrating video visits requires considering how technology can be proactively integrated into practice. A policy that promotes platform flexibility will be crucial in fostering video integration.
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Affiliation(s)
- Emily Franzosa
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J. Peters VA Medical Center, Bronx, NY, USA
| | | | | | - Bruce Leff
- Johns Hopkins University, Baltimore, MD, USA
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Brody AA, Barnes DE, Chodosh J, Galvin JE, Hepburn KW, Troxel AB, Hom K, McCarthy EP, Unroe KT. Building a National Program for Pilot Studies of Embedded Pragmatic Clinical Trials in Dementia Care. J Am Geriatr Soc 2021; 68 Suppl 2:S14-S20. [PMID: 32589282 DOI: 10.1111/jgs.16618] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 02/28/2020] [Revised: 04/03/2020] [Accepted: 04/10/2020] [Indexed: 12/24/2022]
Abstract
Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation's ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14-S20, 2020.
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Affiliation(s)
- Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA.,Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, New York, USA
| | - Deborah E Barnes
- Department of Psychiatry and Epidemiology & Biostatistics, University of California, San Francisco School of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Joshua Chodosh
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, New York, USA
| | - James E Galvin
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Andrea B Troxel
- Division of Biostatistics, NYU Grossman School of Medicine, New York, New York, USA
| | - Kimberly Hom
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen T Unroe
- Center for Aging Research, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA
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37
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Ritchie CS, Gallopyn N, Sheehan OC, Sharieff SA, Franzosa E, Gorbenko K, Ornstein KA, Federman AD, Brody AA, Leff B. COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey. J Am Med Dir Assoc 2021; 22:1338-1344. [PMID: 34111388 PMCID: PMC8184288 DOI: 10.1016/j.jamda.2021.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/13/2021] [Accepted: 05/16/2021] [Indexed: 12/02/2022]
Abstract
Objectives Approximately 7.5 million US adults are homebound or have difficulty accessing office-based primary care. Home-based primary care (HBPC) provides such patients access to longitudinal medical care at home. The purpose of this study was to describe the challenges and adaptations by HBPC practices made during the first surge of the COVID-19 pandemic. Design Mixed-methods national survey. Setting and Participants HBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs. Methods Online survey regarding practice responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Descriptive statistics and t tests described frequency distributions of nominal and categorical data; qualitative content analysis was used to summarize responses to the open-ended questions. Results Seventy-nine practices across 29 states were included in the final analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices pivoted to new use of video visits (76.3%). The most common challenges were as follows: patient lack of familiarity with telemedicine (81.9%), patient anxiety (77.8%), clinician anxiety (69.4%), technical difficulties reaching patients (66.7%), and supply shortages including masks, gown, and disinfecting materials (55.6%). Top adaptive strategies included using telemedicine (95.8%), reducing in-person visits (81.9%), providing resources for patients (52.8%), and staff training in PPE use and COVID testing (52.8%). Conclusions and Implications HBPC practices experienced a wide array of COVID-19–related challenges. Most continued to see patients in the home, augmented visits with telemedicine and creatively adapted to the challenges. An increased recognition of the need for in-home care by health systems who observed its critical role in caring for fragile older adults may serve as a silver lining to the otherwise dark sky of the COVID-19 pandemic.
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Affiliation(s)
- Christine S Ritchie
- Massachusetts General Hospital Department of Medicine, Division of Palliative Care and Geriatric Medicine, Boston, MA, USA; Massachusetts General Hospital Mongan Institute, Boston, MA, USA; Harvard Medical School Center for Palliative Care, Boston, MA, USA.
| | - Naomi Gallopyn
- Massachusetts General Hospital Department of Medicine, Division of Palliative Care and Geriatric Medicine, Boston, MA, USA; Massachusetts General Hospital Mongan Institute, Boston, MA, USA
| | - Orla C Sheehan
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shanaz Ahmed Sharieff
- Massachusetts General Hospital Department of Medicine, Division of Palliative Care and Geriatric Medicine, Boston, MA, USA; Massachusetts General Hospital Mongan Institute, Boston, MA, USA
| | - Emily Franzosa
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | - Bruce Leff
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Groom LL, Brody AA, Squires AP. Defining Telepresence as Experienced in Telehealth Encounters: A Dimensional Analysis. J Nurs Scholarsh 2021; 53:709-717. [PMID: 34060218 DOI: 10.1111/jnu.12684] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Telehealth's uptake has increased substantially in recent years, with an especially large jump in 2020 due to the emergence of COVID-19. This article provides background on and explores "telepresence" in healthcare literature. Telepresence strongly impacts the patient experience, but it is poorly defined in current research. The aim was to conceptually define telepresence using qualitative methods. DESIGN Dimensional analysis was used to analyze telepresence in clinical literature and create a clearer definition of telepresence as a concept. Multiple databases were searched for articles related to telepresence. Thirteen international articles related to telepresence were selected for analysis. METHODS Dimensional analysis allowed for multiple viewpoints to be explored within each distinct context and perspective. FINDINGS Twenty-five dimensions were discovered within the articles, which were synthesized to seven core dimensions of telepresence: connection, technological mediation, experienced realism, trust, being supportive, collaboration, and emotional consequence. CONCLUSIONS Telepresence is highly impactful on the patient's experience of telehealth care visits. The conceptual map produced by this dimensional analysis provides direction for clinicians to improve their ability to be present with patients during telehealth care. Potential implications include a starting point for future qualitative research, and the use of this dimensional analysis to inform clinical guidelines, improve clinician training, and assist in the development of new care models. CLINICAL RELEVANCE A telepresence definition brings clarity to an ill-defined concept. COVID-19 magnifies the need for a better understanding of telepresence, which allows clinicians to improve telehealth encounters.
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Affiliation(s)
- Lisa L Groom
- Upsilon, PhD Candidate, New York University Rory Meyers College of Nursing, New York, NY, USA
| | - Abraham A Brody
- Upsilon, Associate Professor of Nursing and Medicine, New York University, New York, NY, USA
| | - Allison P Squires
- Upsilon, Associate Professor & Director, Florence S. Downs PhD Program in Nursing Research & Theory Development, Rory Meyers College of Nursing, and Research Associate Professor, Department of General Internal Medicine, Grossman School of Medicine, New York University, New York, NY, USA
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Martin JL, Hernandez D, Cadogan MP, Brody AA, Alessi CA, Mitchell MN, Song Y, Smilowitz J, Vedvyas A, Qian Y, Zhong H, Chodosh J. Environmental Noise in New York City Long-Term Care Facilities: A Window Into the COVID-19 Pandemic. J Am Med Dir Assoc 2021; 22:974-976. [PMID: 33722568 PMCID: PMC7885630 DOI: 10.1016/j.jamda.2021.02.010] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/12/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Jennifer L Martin
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Diana Hernandez
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Abraham A Brody
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, NY, USA; Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York, NY, USA
| | - Cathy A Alessi
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Michael N Mitchell
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Yeonsu Song
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; UCLA School of Nursing Los Angeles, CA, USA
| | - Jessica Smilowitz
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, NY, USA
| | - Alok Vedvyas
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, NY, USA
| | - Yingzhi Qian
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Hua Zhong
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Joshua Chodosh
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, NY, USA; VA New York Harbor Health Care System, New York, NY, USA.
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Groom LL, McCarthy MM, Stimpfel AW, Brody AA. Telemedicine and Telehealth in Nursing Homes: An Integrative Review. J Am Med Dir Assoc 2021; 22:1784-1801.e7. [PMID: 33819450 DOI: 10.1016/j.jamda.2021.02.037] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [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: 08/31/2020] [Revised: 02/12/2021] [Accepted: 02/21/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Telemedicine and telehealth are increasingly used in nursing homes (NHs). Their use was accelerated further by the COVID-19 pandemic, but their impact on patients and outcomes has not been adequately investigated. These technologies offer promising avenues to detect clinical deterioration early, increasing clinician's ability to treat patients in place. A review of literature was executed to further explore the modalities' ability to maximize access to specialty care, modernize care models, and improve patient outcomes. DESIGN Whittemore and Knafl's integrative review methodology was used to analyze quantitative and qualitative studies. SETTING AND PARTICIPANTS Primary research conducted in NH settings or focused on NH residents was included. Participants included clinicians, NH residents, subacute patients, and families. METHODS PubMed, Web of Science, CINAHL, Embase, PsycNET, and JSTOR were searched, yielding 16 studies exploring telemedicine and telehealth in NH settings between 2014 and 2020. RESULTS Measurable impacts such as reduced emergency and hospital admissions, financial savings, reduced physical restraints, and improved vital signs were found along with process improvements, such as expedient access to specialists. Clinician, resident, and family perspectives were also discovered to be roundly positive. Studies showed wide methodologic heterogeneity and low generalizability owing to small sample sizes and incomplete study designs. CONCLUSIONS AND IMPLICATIONS Preliminary evidence was found to support geriatrician, psychiatric, and palliative care consults through telemedicine. Financial and clinical incentives such as Medicare savings and reduced admissions to hospitals were also supported. NHs are met with increased challenges as a result of the COVID-19 pandemic, which telemedicine and telehealth may help to mitigate. Additional research is needed to explore resident and family opinions of telemedicine and telehealth use in nursing homes, as well as remote monitoring costs and workflow changes incurred with its use.
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Affiliation(s)
- Lisa L Groom
- New York University Rory Meyers College of Nursing, New York, NY, USA.
| | | | | | - Abraham A Brody
- New York University Rory Meyers College of Nursing, New York, NY, USA; Hartford Institute for Geriatric Nursing, New York, NY, USA; Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, NYU Grossman School of Medicine, New York, NY, USA
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Franzosa E, Gorbenko K, Brody AA, Leff B, Ritchie CS, Kinosian B, Ornstein KA, Federman AD. "At Home, with Care": Lessons from New York City Home-based Primary Care Practices Managing COVID-19. J Am Geriatr Soc 2021; 69:300-306. [PMID: 33179761 PMCID: PMC8285037 DOI: 10.1111/jgs.16952] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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: 08/06/2020] [Revised: 10/09/2020] [Accepted: 11/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES COVID-19 required rapid innovation throughout the healthcare system. Home-based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands-on, model of care to accommodate restrictions on in-person contact. Our aim was to determine strategies used by New York City (NYC)-area HBPC practices to provide patient care during the first wave of the COVID-19 pandemic with the goal of informing planning and preparation for home-based practices nationwide. DESIGN Cross-sectional qualitative design using semi-structured interviews. SETTING HBPC practices in the NYC metro area during spring 2020. PARTICIPANTS HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC-area practices. MEASUREMENTS Semi-structured interviews explored HBPC practices' COVID-19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end-of-life care, telehealth, community-based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach. RESULTS Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID-19, such as patient outreach and telehealth. HBPC-specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in-person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long-standing patients. CONCLUSION NYC-area HBPC providers adapted care delivery and operations rapidly during the height of the COVID-19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges.
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Affiliation(s)
- Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, New York, USA
| | - Ksenia Gorbenko
- Department of Population Health Science and Policy, Institute of Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Abraham A Brody
- Hartford Institute of Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatrics, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Kinosian
- Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Geriatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex D Federman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Bristol AA, Chaudhry S, Assis D, Wright R, Moriyama D, Harwood K, Brody AA, Charytan DM, Chodosh J, Scherer JS. An Exploratory Qualitative Study of Patient and Caregiver Perspectives of Ambulatory Kidney Palliative Care. Am J Hosp Palliat Care 2021; 38:1242-1249. [PMID: 33438435 DOI: 10.1177/1049909120986121] [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] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The ideal clinical model to deliver palliative care to patients with advanced kidney disease is currently unknown. Internationally, ambulatory kidney palliative care clinics have emerged with positive outcomes, yet there is limited data from the United States (US). In this exploratory study we report perceptions of a US-based ambulatory kidney palliative care clinic from the perspective of patient and caregiver attendees. The objective of this study was to inform further improvement of our clinical program. METHODS Semi-structured interviews were conducted to elicit the patient and caregiver experience. Eleven interviews (8 patients with chronic kidney disease stage IV or V and 3 caregivers) were analyzed using qualitative description design. RESULTS We identified 2 themes: "Communication addressing the emotional and physical aspects of disease" and "Filling gaps in care"; Subthemes include perceived value in symptom management, assistance with coping with disease, engagement in advance care planning, program satisfaction and patient activation. SIGNIFICANCE OF RESULTS Qualitative analysis showed that attendees of an ambulatory kidney palliative care clinic found the clinic enhanced the management of their kidney disease and provided services that filled current gaps in their care. Shared experiences highlight the significant challenges of life with kidney disease and the possible benefits of palliative care for this population. Further study to determine the optimal model of care for kidney palliative care is needed. Inclusion of the patient and caregiver perspective will be essential in this development.
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Affiliation(s)
- Alycia A Bristol
- 16177University of Utah College of Nursing, Salt Lake City, UT, USA
| | | | - Dana Assis
- 1940Yale New Haven Health, New Haven, CT, USA
| | | | - Derek Moriyama
- 12223Keck School of Medicine of University of Southern California, CA, USA
| | - Katherine Harwood
- Columbia University-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, NY, USA.,Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
| | - David M Charytan
- Division of Nephrology, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
| | - Joshua Chodosh
- Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
| | - Jennifer S Scherer
- Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA.,Division of Nephrology, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
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Lin SY, Schneider CE, Bristol AA, Clancy M, Sprague SA, Aldridge M, Cortes T, Goldfeld KS, Kutner JS, Mitchell SL, Shega JW, Wu B, Zhu CW, Brody AA. Findings of Sequential Pilot Trials of Aliviado Dementia Care to Inform an Embedded Pragmatic Clinical Trial. The Gerontologist 2020; 62:304-314. [DOI: 10.1093/geront/gnaa220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Indexed: 12/21/2022] Open
Abstract
Abstract
Background and Objectives
Many investigators of Alzheimer’s disease and related dementias (AD/ADRD) are unfamiliar with the embedded pragmatic clinical trials (ePCTs) and the indispensable pilot phase preceding ePCTs. This paper provides a much-needed example for such a pilot phase and discusses implementation barriers and additional infrastructure and implementation strategies developed in preparation for a nationwide AD/ADRD ePCT.
Research Design and Methods
Two pilot trials were conducted in 2 hospices sequentially to refine and test Aliviado Dementia Care—Hospice Edition, a complex quality improvement intervention for advanced dementia symptom management. Readiness for the subsequent full-scale ePCT was assessed by three milestones: ≥80% training completion rate (“feasibility”), ≥80% posttraining survey respondents indicating intention for practice changes (“applicability”), and at least 1 Aliviado care plan/assessment instrument administered in ≥75% of dementia patients admitted to home hospice within 1-month posttraining (“fidelity”).
Results
Participants included 72 interdisciplinary team members and 11 patients with AD/ADRD across the pilots. Feasibility, applicability, and fidelity outcomes (92%, 93%, and 100%, respectively) all surpassed the preestablished milestones (80%, 80%, and 75%). Main implementation challenges were related to hospice staff turnover, integration of the Aliviado toolbox materials within the electronic health records, and hospices’ limited research experience and infrastructure.
Discussion and Implications
This pilot phase demonstrated feasibility, applicability, and fidelity required to proceed to the full-scale ePCT. Our study findings and discussions of additional infrastructure and implementation strategies developed following the pilot phase can inform researchers and clinicians interested in conducting AD/ADRD-related pilot studies for ePTCs or quality improvement initiatives.
Clinical Trials Registration Number
NCT03681119
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Affiliation(s)
- Shih-Yin Lin
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Catherine E Schneider
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Alycia A Bristol
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Maureen Clancy
- MJHS Hospice and Palliative Care, New York, New York, USA
| | - Sara A Sprague
- Providence TrinityCare Hospice, Torrance, California, USA
| | - Melissa Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters VA Medical Center, Bronx, New York, USA
| | - Tara Cortes
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Keith S Goldfeld
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Jean S Kutner
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Joseph W Shega
- Vitas Healthcare, Miami, Florida, USA
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Bei Wu
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Carolyn W Zhu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters VA Medical Center, Bronx, New York, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
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Murali KP, Merriman JD, Yu G, Vorderstrasse A, Kelley A, Brody AA. An Adapted Conceptual Model Integrating Palliative Care in Serious Illness and Multiple Chronic Conditions. Am J Hosp Palliat Care 2020; 37:1086-1095. [PMID: 32508110 PMCID: PMC7483852 DOI: 10.1177/1049909120928353] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Seriously ill adults with multiple chronic conditions (MCC) who receive palliative care may benefit from improved symptom burden, health care utilization and cost, caregiver stress, and quality of life. To guide research involving serious illness and MCC, palliative care can be integrated into a conceptual model to develop future research studies to improve care strategies and outcomes in this population. METHODS The adapted conceptual model was developed based on a thorough review of the literature, in which current evidence and conceptual models related to serious illness, MCC, and palliative care were appraised. Factors contributing to patients' needs, services received, and service-related variables were identified. Relevant patient outcomes and evidence gaps are also highlighted. RESULTS Fifty-eight articles were synthesized to inform the development of an adapted conceptual model including serious illness, MCC, and palliative care. Concepts were organized into 4 main conceptual groups, including Factors Affecting Needs (sociodemographic and social determinants of health), Factors Affecting Services Received (health system; research, evidence base, dissemination, and health policy; community resources), Service-Related Variables (patient visits, service mix, quality of care, patient information, experience), and Outcomes (symptom burden, quality of life, function, advance care planning, goal-concordant care, utilization, cost, death, site of death, satisfaction). DISCUSSION The adapted conceptual model integrates palliative care with serious illness and multiple chronic conditions. The model is intended to guide the development of research studies involving seriously ill adults with MCC and aid researchers in addressing relevant evidence gaps.
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Affiliation(s)
| | | | - Gary Yu
- 5894NYU Rory Meyers College of Nursing, New York, NY, USA
| | - Allison Vorderstrasse
- Florence S. Downs PhD Program in Nursing Research and Theory, 5894NYU Rory Meyers College of Nursing, New York, NY, USA
| | - Amy Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 5925Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, 5894NYU Rory Meyers College of Nursing, New York, NY, USA
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Jones TM, Brody AA. Adaptation and Piloting for Hospice Social Workers of Aliviado Dementia Care, a Dementia Symptom Management Program. Am J Hosp Palliat Care 2020; 38:452-458. [PMID: 33016082 DOI: 10.1177/1049909120962459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 11/16/2022] Open
Abstract
BACKGROUND Forty-five percent of hospice patients currently have a primary or secondary diagnosis of Alzheimer's disease or related disorders. However, few programs have focused specifically on assisting hospices in providing evidence-based symptom management to persons living with dementia (PLWD). OBJECTIVE To adapt and pilot the training component of Aliviado Dementia Care, a dementia symptom management quality improvement program originally developed for home healthcare, for use by social workers as part of the hospice interdisciplinary team. DESIGN A prospective pre-post design was utilized, measuring knowledge, confidence, and attitudes at baseline, and immediately and 1-month post-training. Analysis was performed using paired t-tests and repeated measures ANOVA. SUBJECTS Hospice social workers currently practicing in the United States with at least 1 year of experience. MEASUREMENTS The Dementia Symptom Knowledge Assessment and a post-training continuing education evaluation form. RESULTS Forty-six subjects were enrolled, of whom 26 completed the first post-test and 23 both post-tests. There was a poor baseline level of knowledge and confidence in caring for PLWD. Significant improvements occurred following training, particularly in implementing non-pharmacologic interventions for behavioral and psychological symptoms of dementia (BPSD) (16.64% increase, p < .0001) and confidence in managing behavioral symptoms (16.86%, p = .01) and depression (25.18%, p < .0001). Changes were maintained over time. All respondents were either very satisfied or satisfied with the quality and content of the program. CONCLUSIONS The training modules of Aliviado Dementia Care were successfully tailored for use by hospice social workers, showing significant improvement in knowledge and confidence in caring for behavioral symptoms in PLWD. Future work will examine whether the larger program, including this training, can subsequently improve patient outcomes in hospice.
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Affiliation(s)
- Tessa M Jones
- 5894New York University Silver School of Social Work, New York, NY, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, 5894New York University Rory Meyers College of Nursing, New York, NY, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, USA
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Brody AA, Sadarangani T, Jones TM, Convery K, Groom L, Bristol AA, David D. Family- and Person-Centered Interdisciplinary Telehealth: Policy and Practice Implications Following Onset of the COVID-19 Pandemic. J Gerontol Nurs 2020; 46:9-13. [PMID: 32845343 DOI: 10.3928/00989134-20200811-03] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
With the onset of the COVID-19 pandemic, telehealth was thrust to the forefront, becoming one of the most predominant forms of care almost overnight. Despite years of research, practice, and policymaking, tenets for providing telehealth in an interdisciplinary, family- and person-centered fashion, and across a wide breadth of settings remain underdeveloped. In addition, although telehealth has the potential to increase equity in care, it can also further exacerbate disparities. The current article discusses the opening created by the pandemic and provides recommendations for how to make permanent changes in telehealth policy and practice to allow for interdisciplinary, person- and family-centered care while also taking care to address issues of equity and ethics and privacy issues related to telehealth and remote monitoring. [Journal of Gerontological Nursing, 46(9), 9-13.].
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Schneider CE, Bristol A, Ford A, Lin SY, Palmieri J, Meier MR, Brody AA. The Impact of Aliviado Dementia Care-Hospice Edition Training Program on Hospice Staff's Dementia Symptom Knowledge. J Pain Symptom Manage 2020; 60:e7-e13. [PMID: 32416231 PMCID: PMC7725371 DOI: 10.1016/j.jpainsymman.2020.05.010] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 01/21/2023]
Abstract
CONTEXT As the aging population grows, the incidence of dementia continues to increase substantially. However, the lack of a significant geriatric health care workforce as well as little dementia training among generalist health care workers leads to suboptimal care for persons living with dementia (PLWD). In particular, few evidence-based interventions exist to improve the quality of dementia care among hospice interdisciplinary teams caring for PLWD. Aliviado Dementia Care-Hospice Edition is a quality assurance and performance improvement program that includes training, mentoring, and workflow enhancements, which aims to improve quality of hospice care provided to PLWD and their caregivers. OBJECTIVES To determine the effectiveness of the Aliviado Dementia Care program in increasing dementia symptom knowledge of hospice interdisciplinary team members. METHODS About 53 hospice team members from two diverse hospices, consisting of social workers, chaplains, physicians, and nurses, participated in the Aliviado training program. In this prepost trial, 39 participants completed the Dementia Symptom Knowledge Assessment before and after completion of the program. RESULTS Paired t-tests showed significant differences before and after Aliviado training in depression knowledge and confidence, as well as behavioral and psychological symptoms of dementia (BPSD) knowledge, confidence, and interventions. The greatest percent change increases were in depression (15.2%) and BPSD (13.3%) confidence as well as BPSD interventions (18.4%). Qualitative feedback consistently emphasized that trainees could now effectively assess their patients for specific symptoms such as pain and agitation. CONCLUSION Aliviado is an evidence-based system-level intervention that improves clinical knowledge, attitudes, and confidence in treating PLWD enrolled in hospice.
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Affiliation(s)
- Catherine E Schneider
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA.
| | - Alycia Bristol
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Ariel Ford
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Shih-Yin Lin
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | | | | | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
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Bristol AA, Convery KA, Sotelo V, Schneider CE, Lin SY, Fletcher J, Rupper R, Galvin JE, Brody AA. Protocol for an embedded pragmatic clinical trial to test the effectiveness of Aliviado Dementia Care in improving quality of life for persons living with dementia and their informal caregivers. Contemp Clin Trials 2020; 93:106005. [PMID: 32320844 PMCID: PMC7269690 DOI: 10.1016/j.cct.2020.106005] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/27/2020] [Accepted: 04/13/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Persons living with Alzheimer's disease and related dementias (ADRD) frequently experience pain and behavioral and psychological symptoms of dementia (BPSD) which decrease quality of life (QOL) and influence caregiver burden. Home healthcare professionals however may underrecognize or lack the ability to manage BPSD. INTERVENTION This protocol describes an ADRD palliative quality assurance performance improvement program for home healthcare, Aliviado Dementia Care-Home Health Edition. It includes training, mentoring, and a toolbox containing intervention strategies. METHODS This embedded pragmatic clinical trial will utilize a multi-site, cluster randomized control design. Recruitment will occur from three home healthcare agencies located in New Jersey, Utah, and Florida. At each agency, care teams will be randomized as clusters and assigned to either the Aliviado Dementia Care program or usual care. We plan to enroll 345 persons living with ADRD and their informal caregiver dyads. The primary outcome will be to measure QOL in both the person living with ADRD and their informal caregiver, and emergency department visits and hospital admissions. Secondary outcomes in the person living with ADRD will include the examination of pain, BPSD, antipsychotic and analgesic use. Secondary outcomes in caregivers include burden, depressive symptoms, functional health and wellbeing, and healthcare utilization. CONCLUSION This study will be the first large-scale embedded pragmatic clinical trial in home healthcare focused on care quality and outcomes in addressing QOL in ADRD. If proven successful, the intervention can then be disseminated to agencies throughout the country to improve the quality of care for this vulnerable, underserved population. TRIAL REGISTRATION Clinical Trials.gov: NCT03255967.
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Affiliation(s)
| | - Kimberly A Convery
- The Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, United States
| | - Victor Sotelo
- The Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, United States
| | | | - Shih-Yin Lin
- NYU Rory Meyers College of Nursing, United States
| | | | - Randall Rupper
- University of Utah School of Medicine, United States; George E. Wahlen Department of Veterans Affairs Medical Center, VA Salt Lake City Health Care System, Geriatric Research, Education and Clinical Center, Salt Lake City, UT, United States
| | - James E Galvin
- Comprehensive Center for Brain Health, University of Miami Miller School of Medicine, United States
| | - Abraham A Brody
- The Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, United States.
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Reckrey JM, Geduldig ET, Lindquist LA, Morrison RS, Boerner K, Federman AD, Brody AA. Paid Caregiver Communication With Homebound Older Adults, Their Families, and the Health Care Team. Gerontologist 2020; 60:745-753. [PMID: 31112604 DOI: 10.1093/geront/gnz067] [Citation(s) in RCA: 7] [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] [Received: 01/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although paid caregivers (e.g., home health aides and home care workers) provide essential care for homebound older adults with serious illness in their homes, little is known about how and to whom paid caregivers communicate about the health needs they encounter. This study explored how paid caregivers (i) communicate when older adults experience symptoms or clinical changes and (ii) interact with the health care team. RESEARCH DESIGN AND METHODS We conducted separate one-on-one, semi-structured interviews (n = 30) lasting 40-60 min with homebound older adults (or their proxies if they had cognitive impairment) and their paid caregivers (provided they had worked with the older adult for ≥8 hr per week for ≥6 months). Interviews were audio-recorded, transcribed, and coded. RESULTS Thematic analysis identified four themes: (i) older adults or their families were the gatekeepers to paid caregiver communication with the health care team; (ii) communication between older adults, their families, and paid caregivers was enhanced when close relationships were present; (iii) paid caregivers responded to health care team inquiries but rarely communicated proactively; and (4) most older adults, families, and paid caregivers were satisfied with existing paid caregiver communication with the health care team. DISCUSSION AND IMPLICATIONS Rather than discuss concerns with the health care team, paid caregivers communicated directly with older adults or their families about the health needs they encounter. Understanding how communication occurs in the home is the first step to maximizing the potentially positive impact of paid caregivers on the health of older adults living at home.
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Affiliation(s)
- Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emma T Geduldig
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lee A Lindquist
- Department of Medicine, Division of General Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,James J Peters Bronx VA Geriatric Research Education and Clinical Center, New York, New York
| | - Kathrin Boerner
- Department of Gerontology, University of Massachusetts Boston, New York
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York
| | - Abraham A Brody
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,James J Peters Bronx VA Geriatric Research Education and Clinical Center, New York, New York.,New York University Rory Meyers College of Nursing
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Luth EA, Russell DJ, Brody AA, Dignam R, Czaja SJ, Ryvicker M, Bowles KH, Prigerson HG. Race, Ethnicity, and Other Risks for Live Discharge Among Hospice Patients with Dementia. J Am Geriatr Soc 2020; 68:551-558. [PMID: 31750935 PMCID: PMC7056492 DOI: 10.1111/jgs.16242] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 08/09/2019] [Revised: 10/06/2019] [Accepted: 10/10/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The end-of-life trajectory for persons with dementia is often protracted and difficult to predict, placing these individuals at heightened risk of live discharge from hospice. Risks for live discharge due to condition stabilization or failure to decline among patients with dementia are not well established. Our aim was to identify demographic, health, and hospice service factors associated with live discharge due to condition stabilization or failure to decline among hospice patients with dementia. DESIGN Retrospective cohort study. SETTING A large not-for-profit agency in New York City. PARTICIPANTS A total of 2629 hospice patients with dementia age 65 years and older. MEASUREMENTS Primary outcome was live discharge from hospice due to condition stabilization or failure to decline (vs death). Measures include demographic factors (race/ethnicity, Medicaid, sex, age, marital status, parental status), health characteristics (primary dementia diagnosis, comorbidities, functional status, prior hospitalization), and hospice service (location, length of service, number and timing of nurse visits). RESULTS Logistic regression models indicated that compared with white hospice patients with dementia, African American and Hispanic hospice patients with dementia experienced increased risk of live discharge (African American: adjusted odds ratio [aOR] = 2.42; 95% confidence interval [CI] = 1.34-4.38; Hispanic: aOR = 2.99; 95% CI = 1.81-4.94). Home hospice (aOR = 7.57; 95% CI = 4.04-14.18), longer length of service (aOR = 1.04; 95% CI = 1.04-1.05), and more days between nurse visits and discharge (aOR = 1.86; 95% CI = 1.56-2.21) were also associated with live discharge. CONCLUSION To avoid burdensome and disruptive transitions out of hospice in patients with dementia, interventions to reduce live discharge due to condition stabilization or failure to decline should be tailored to meet the needs of African American, Hispanic, and home hospice patients. Policies regarding sustained hospice eligibility should account for the variable and protracted end-of-life trajectory of patients with dementia. J Am Geriatr Soc 68:551-558, 2020.
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Affiliation(s)
| | - David J. Russell
- Center for Home Care Policy & Research, Visiting Nurse
Service of New York
- Department of Sociology Appalachian State University
| | - Abraham A. Brody
- New York University College of Nursing
- James J Peters Bronx VA Medical Center, GRECC
| | - Ritchell Dignam
- Center for Home Care Policy & Research, Visiting Nurse
Service of New York
| | | | - Miriam Ryvicker
- Center for Home Care Policy & Research, Visiting Nurse
Service of New York
| | - Kathryn H. Bowles
- Center for Home Care Policy & Research, Visiting Nurse
Service of New York
- University of Pennsylvania School of Nursing
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