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Shin JH, Jung SO, Min EJ. Factors Influencing Hospitalization of Nursing Home Residents in Korea Using Regularized Negative Binomial Regression. Policy Polit Nurs Pract 2024; 25:141-151. [PMID: 38874520 DOI: 10.1177/15271544241259427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
The appropriateness of hospitalization for nursing home (NH) residents is still up for debate, with determining factors including timeliness, available treatment, healthcare staff, medication options in hospitals, and safety issues. Although the factors leading to hospitalization have been studied expansively, research on staffing is limited. Thus, this study aimed to investigate organizational predictors, nurse staffing, and government incentives and find important factors to hospitalization due to infection or disease among NH residents in Korea. A cross-sectional design was used, and data were collected via survey from a total of 51 NHs from August 27, 2021 to March 25, 2022. A total of 32 explanatory variables were included. The response variable was the count of hospitalized residents due to infection or disease. We analyzed data using least absolute shrinkage and negative binomial regression. We found that registered nurses' increased hours per resident day were related to decreased hospitalizations due to infection or disease. Appropriate retention and recruitment of nurse staffing with professional leadership should be performed to increase the quality of care for NH residents.
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Affiliation(s)
- Juh H Shin
- School of Nursing, George Washington University, USA
| | - Sun O Jung
- College of Nursing, Ewha Womans University, Korea
| | - Eun J Min
- College of Medicine, The Catholic University of Korea, Korea
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2
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Chebib N, Holmes E, Maniewicz S, Abou-Ayash S, Srinivasan M, McKenna G, Kossioni A, Schimmel M, Müller F, Brocklehurst P. Exploring preferences of older adults for dental services: A pilot multi-national discrete choice experiment. Gerodontology 2024; 41:220-230. [PMID: 37309614 DOI: 10.1111/ger.12696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To pilot an exploration of older adults' future preferences using discrete choice experiments to understand who should provide dental examinations and treatment, where these services should be provided, and participants' willingness to pay and willingness to travel. BACKGROUND The proportion of older adults in the general population is increasing and is recognised as a pressing public health challenge. MATERIALS AND METHODS Older people aged 65 years and over were recruited into this study from the UK, Switzerland and Greece. Drawing on earlier stakeholder engagement, a set of choice experiments are developed to explore the future preferences of older people for dental examinations and dental treatment, as they anticipated losing their independence. These were presented to the participants using a range of platforms, because of the COVID pandemic. Data were analysed in STATA using a random-effects logit model. RESULTS Two hundred and forty-six participants (median age 70 years) completed the pilot study. There was a strong preference across all countries for a dentist to undertake a dental examination (Greece: β = 0.944, Switzerland: β = 0.260, UK β = 0.791), rather than a medical doctor (Greece: β = -0.556, Switzerland: β = -0.4690, UK: β = -0.468). Participants in Switzerland and the UK preferred these examinations to be undertaken in a dental practice (Switzerland: β = 0.220, UK: β = 0.580) while participants in Greece preferred the dental examination to be undertaken in their homes (β = 1.172). Greek participants preferred dental treatment to be undertaken by a specialist (β = 0.365) in their home (β = 0.862), while participants from the UK and Switzerland preferred to avoid any dental treatment at home (Switzerland: β = -0.387; UK: β = -0.444). Willingness to pay analyses highlighted that participants in Switzerland and the UK were willing to pay more to ensure the continuity of future service provision at a family dental practice (Switzerland: β = 0.454, UK: β = 0.695). CONCLUSION Discrete choice experiments are valuable for exploring older people's preferences for dental service provision in different countries. Future larger studies should be conducted to further explore the potential of this approach, given the pressing need to design services that are fit for purpose for older people. Continuity of dental service provision is considered as important by most older people, as they anticipate losing their dependence.
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Affiliation(s)
- Najla Chebib
- Division of Gerodontology and Removable Prosthodontics, University Clinics of Dental Medicine, University of Geneva, Geneva, Switzerland
| | - Emily Holmes
- Centre for Health Economics and Medicines Evaluation (CHEME), School of Health Sciences, Bangor University, Bangor, UK
| | - Sabrina Maniewicz
- Division of Gerodontology and Removable Prosthodontics, University Clinics of Dental Medicine, University of Geneva, Geneva, Switzerland
| | - Samir Abou-Ayash
- Division of Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland
| | - Murali Srinivasan
- Clinic of General- Special care- and Geriatric Dentistry, Center of Dental Medicine, University of Zürich, Zürich, Switzerland
| | - Gerald McKenna
- Health Services Research Group, Centre for Public Health, Queens University Belfast, Belfast, UK
| | - Anastasia Kossioni
- Division of Gerodontology, Department of Prosthodontics, Dental School of the National and Kapodistrian University of Athens, Athens, Greece
| | - Martin Schimmel
- Division of Gerodontology and Removable Prosthodontics, University Clinics of Dental Medicine, University of Geneva, Geneva, Switzerland
- Centre for Health Economics and Medicines Evaluation (CHEME), School of Health Sciences, Bangor University, Bangor, UK
| | - Frauke Müller
- Division of Gerodontology and Removable Prosthodontics, University Clinics of Dental Medicine, University of Geneva, Geneva, Switzerland
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Xie Z, Chen G, Oladeru OT, Hamadi HY, Montgomery L, Robinson MT, Hong YR. Inpatient Palliative Care and Healthcare Utilization Among Older Patients With Alzheimer's Disease and Related Dementia (ADRD) and High Risk of Mortality in U.S. Hospitals. Am J Hosp Palliat Care 2024:10499091241252685. [PMID: 38710104 DOI: 10.1177/10499091241252685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024] Open
Abstract
Background. Despite the potential of palliative care (PC) to enhance the quality of life for patients with advanced dementia, there is limited knowledge of its inpatient utilization patterns. This study investigated inpatient PC consultation utilization patterns and evaluated its impact on hospital length of stay (LOS) and medical costs among older patients diagnosed with Alzheimer's Disease and Related Dementia who were at a high risk of mortality (ADRD-HRM). Methods. Using the 2016-2019 National Inpatient Sample database, we conducted multivariable logistic regression analyses to identify individual and hospital characteristics influencing PC consultation utilization. We subsequently performed generalized linear models to estimate LOS (using Poisson distribution) and hospital charges (via log-transformation). Results. Our sample encompassed 965,644 hospital discharges (weighted n = 4,828,219) of patients aged 65 years and above with ADRD-HRM. Among them, 14.6% received inpatient PC. There was a notable uptrend in PC consultation utilization from 13.3% in 2016 to 16.3% in 2019 (p trend<.001). Factors positively influencing and associated with PC utilization included patients that are older, non-Hispanic White, with higher income, receiving care from teaching hospitals, and facilitated with greater bed capacity (all P < .05). Although patients who received PC were more likely to have 3.0% longer LOS (P < .001), they had 19.2% lower hospital charges (P < .001). Conclusions. PC substantially reduced hospital expenditures for older patients with ADRD-HRM, but the prevalence remained low at 14.6% in the study period. Future studies should explore the unmet needs of patients with lower sociodemographic status and those in rural hospitals to further increase their PC consultation utilization.
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Affiliation(s)
- Zhigang Xie
- Department of Public Health, University of North Florida, Jacksonville, FL, USA
| | - Guanming Chen
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Hanadi Y Hamadi
- Department of Health Administration, University of North Florida, Jacksonville, FL, USA
| | - Lucinda Montgomery
- Department of Public Health, University of North Florida, Jacksonville, FL, USA
| | | | - Young-Rock Hong
- Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA
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Brotherhood K, Searle B, Spiers GF, Caiado C, Hanratty B. Variations in older people's emergency care use by social care setting: a systematic review of international evidence. Br Med Bull 2024; 149:32-44. [PMID: 38112600 PMCID: PMC10938536 DOI: 10.1093/bmb/ldad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/16/2023] [Accepted: 11/28/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Older adults' use of social care and their healthcare utilization are closely related. Residents of care homes access emergency care more often than the wider older population; however, less is known about emergency care use across other social care settings. SOURCES OF DATA A systematic review was conducted, searching six electronic databases between January 2012 and February 2022. AREAS OF AGREEMENT Older people access emergency care from a variety of community settings. AREAS OF CONTROVERSY Differences in study design contributed to high variation observed between studies. GROWING POINTS Although data were limited, findings suggest that emergency hospital attendance is lowest from nursing homes and highest from assisted living facilities, whilst emergency admissions varied little by social care setting. AREAS TIMELY FOR DEVELOPING RESEARCH There is a paucity of published research on emergency hospital use from social care settings, particularly home care and assisted living facilities. More attention is needed on this area, with standardized definitions to enable comparisons between studies.
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Affiliation(s)
- Kelly Brotherhood
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK
| | - Ben Searle
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK
| | - Gemma Frances Spiers
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK
| | - Camila Caiado
- Department of Mathematical Sciences, Mathematical Sciences & Computer Science Building, Durham University, Upper Mountjoy Campus, Stockton Road, Durham, DH1 3LE, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK
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Zafeiridi E, McMichael A, O’Hara L, Passmore P, McGuinness B. Hospital admissions and emergency department visits for people with dementia. QJM 2024; 117:119-124. [PMID: 37812203 PMCID: PMC10896632 DOI: 10.1093/qjmed/hcad232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/26/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Previous studies have suggested that people with dementia (PwD) are more likely to be admitted to hospital, have prolonged hospital stay, or visit an emergency department (ED), compared to people without dementia. AIM This study assessed the rates of hospital admissions and ED visits in PwD and investigated the causes and factors predicting this healthcare use. Further, this study assessed survival following hospital admissions and ED visits. DESIGN This was a retrospective study with data from 26 875 PwD and 23 961 controls. METHODS Data from national datasets were extracted for demographic characteristics, transitions to care homes, hospital and ED use and were linked through the Honest Broker Service. PwD were identified through dementia medication and through causes for hospital admissions and death. RESULTS Dementia was associated with increased risk of hospital admissions and ED visits, and with lower odds of hospital readmission. Significant predictors for hospital admissions and readmissions in PwD were transitioning to a care home, living in urban areas and being widowed, while female gender and living in less deprived areas reduced the odds of admissions. Older age and living in less deprived areas were associated with lower odds of an ED visit for PwD. In contrast to predictions, mortality rates were lower for PwD following a hospital admission or ED visit. CONCLUSIONS These findings result in a better understanding of hospital and ED use for PwD. Surprisingly, survival for PwD was prolonged following hospital admissions and ED visits and thus, policies and services enabling these visits are necessary, especially for people who live alone or in rural areas; however, increased primary care and other methods, such as eHealth, could provide equally effective care in order to avoid distress and costs for hospital admissions and ED visits.
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Affiliation(s)
- E Zafeiridi
- Centre for Public Health, Queen’s University, Belfast, UK
| | - A McMichael
- Centre for Public Health, Queen’s University, Belfast, UK
| | - L O’Hara
- Centre for Public Health, Queen’s University, Belfast, UK
| | - P Passmore
- Centre for Public Health, Queen’s University, Belfast, UK
| | - B McGuinness
- Centre for Public Health, Queen’s University, Belfast, UK
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Hirooka K, Fukahori H, Ninomiya A, Fukui S, Takahashi K, Anzai T, Ishibashi T. Impact of family involvement and an advance directive to not hospitalize on hospital transfers of residents in long-term care facilities. Arch Gerontol Geriatr 2024; 117:105183. [PMID: 37690255 DOI: 10.1016/j.archger.2023.105183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE With the rapidly aging population, the number of residents transferred to hospitals from long-term care facilities (LTCFs) is increasing globally. The objective of this study was to investigate the association between family involvement and an advance directive (AD) for not hospitalizing and hospital transfers among LTCF residents with dementia. METHOD Using the InterRAI assessment database from September 2014 to June 2019, we included 874 residents from 16 LTCFs in Japan. RESULTS Of the 874 participants, 19.0% had an AD for not hospitalizing, and 20.5% were transferred to hospitals. An AD for not hospitalizing decreased the likelihood of hospital transfers (p = 0.005). Multilevel logistic regression analysis showed that family involvement was not associated with hospital transfers (odds ratio [OR]: 1.18; 95% confidence interval [CI]: 0.77-1.80), while an AD for not hospitalizing was significantly associated with decreased hospital transfers (OR: 0.50; 95% CI: 0.28-0.89) among the LTCF residents. CONCLUSIONS Although ADs are not legally defined in Japan, we found that an AD for not hospitalizing decreased hospital transfers. Given that many older people tend to hesitate to express their wishes in clinical decision-making situations in Japan, regular discussions are necessary to help them express their care preferences while also documenting the discussions to ensure the residents receive high-quality care.
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Affiliation(s)
- Kayo Hirooka
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan; The Dia Foundation for Research on Ageing Societies, Tokyo, Japan.
| | - Hiroki Fukahori
- Division of Gerontological Nursing, Faculty of Nursing and Medical Care, Keio University, Kanagawa, Japan
| | - Ayako Ninomiya
- The Dia Foundation for Research on Ageing Societies, Tokyo, Japan; Division of Fundamental Nursing, Josai International University, Chiba, Japan
| | - Sakiko Fukui
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan; The Dia Foundation for Research on Ageing Societies, Tokyo, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatsuhiko Anzai
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
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7
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Mitchell RJ, Wijekulasuriya S, du Preez J, Lystad R, Chauhan A, Harrison R, Curtis K, Braithwaite J. Population-level quality indicators of end-of-life-care in an aged care setting: Rapid systematic review. Arch Gerontol Geriatr 2024; 116:105130. [PMID: 37535984 DOI: 10.1016/j.archger.2023.105130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/29/2023] [Accepted: 07/14/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND As their health declines, many older adults require additional care and move to residential aged care facilities. Despite efforts to reduce it, variation persists in care quality at the end-of-life (EOL) between facilities. Indicators to monitor care variation are therefore required. This rapid systematic review aims to identify population-level indicators of the quality of end-of-life-care (EOLC) for residents of aged care. METHOD A rapid systematic review of five databases (MEDLINE, Embase, CINAHL, PsycINFO, Scopus) for studies that reported on the development, assessment or validation of at least one measure of EOLC quality for residents living in an aged care setting from 1 January 2000 to 18 April 2023 was conducted. Abstracts and full-texts were screened by two reviewers and each indicator critically appraised. Key characteristics of each study were extracted. RESULTS From seven studies, 106 EOLC quality indicators (75 of which were unique) for aged care residents were identified. Five studies specifically identified EOLC indicators for older residents with cognitive impairment. The EOLC quality indicators were diverse in nature. There were 31 EOLC quality indicators (22 unique indicators) focused on the structure and process of care provided and 51 (38 unique indicators) identified physical and psychological aspects of care. Twenty-three EOLC quality indicators (14 unique indicators) related to care of the imminently dying patient. CONCLUSION A common suite of population-level EOLC indicators that are reflective of care quality, are clinically appropriate, and important to residents and their families should be identified to monitor EOLC quality within and across jurisdictions.
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Affiliation(s)
- Rebecca J Mitchell
- Australian Institute of Health Innovation, Macquarie University, Australia.
| | | | - James du Preez
- Australian Institute of Health Innovation, Macquarie University, Australia
| | - Reidar Lystad
- Australian Institute of Health Innovation, Macquarie University, Australia
| | - Ashfaq Chauhan
- Australian Institute of Health Innovation, Macquarie University, Australia
| | - Reema Harrison
- Australian Institute of Health Innovation, Macquarie University, Australia
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Australia
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Koroukian SM, Douglas SL, Vu L, Fein HL, Gairola R, Warner DF, Schiltz NK, Cullen J, Owusu C, Sajatovic M, Rose J. Aggressive end-of-life care across gradients of cognitive impairment in nursing home patients with metastatic cancer. J Am Geriatr Soc 2023; 71:3546-3553. [PMID: 37515440 PMCID: PMC10907987 DOI: 10.1111/jgs.18526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/13/2023] [Accepted: 06/24/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Studies examining end-of-life (EOL) care in older cancer patients are scarce, and prior studies have not accounted for gradients of cognitive impairment (COG-I). We examine EOL care patterns across COG-I gradients, hypothesizing that greater COG-I severity is associated with lower odds of receiving aggressive EOL care. METHODS Using data from the linked Surveillance Epidemiology and End Results (SEER) -Medicare -Minimum Data Set (MDS) 3.0, we identified patients with nursing facility stays (NFS) and who died with metastatic cancer from 2013 to 2017. Markers of aggressive EOL care were: cancer-directed treatment, intensive care unit admission, >1 emergency department visit, or >1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to evaluate the independent association between COG-I severity and receipt of aggressive EOL care. RESULTS Of the 40,833 patients in our study population, 49.2% were cognitively intact; 24.4% had mild COG-I; 19.7% had moderate COG-I; and 6.7% had severe COG-I. The percent of patients who received aggressive EOL care was 62.6% and 74.2% among those who were cognitively intact and those with severe COG-I, respectively. Compared with cognitively intact patients, those with severe COG-I had 86% higher odds of receiving any type of aggressive EOL care (adjusted odds ratio (aOR): 1.86 (95% confidence interval: 1.70-2.04)), which were primarily associated with higher odds of in-hospital death. The odds of in-hospital death associated with severe COG-I were higher among those with short- than with long-term stays (aOR:2.58 (2.35-2.84) and aOR:1.40 (1.17-1.67), respectively). CONCLUSIONS Contrary to our hypothesis, aggressive EOL care in older metastatic cancer patients with NFS was highest among those suffering severe COG-I. These findings can inform the development of interventions to help reduce aggressive EOL care in this patient population.
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Affiliation(s)
- Siran M. Koroukian
- Department of Population and Quantitative Health Sciences,
Case Western Reserve University School of Medicine, Cleveland, OH
- Case Comprehensive Cancer Center, Case Western Reserve
University School of Medicine, Cleveland, OH
| | - Sara L. Douglas
- Case Comprehensive Cancer Center, Case Western Reserve
University School of Medicine, Cleveland, OH
- Frances Payne Bolton School of Nursing, Case Western
Reserve University, Cleveland, OH
| | - Long Vu
- Department of Population and Quantitative Health Sciences,
Case Western Reserve University School of Medicine, Cleveland, OH
| | - Hannah L. Fein
- Department of Population and Quantitative Health Sciences,
Case Western Reserve University School of Medicine, Cleveland, OH
| | - Richa Gairola
- Department of Epidemiology, School of Public Health, Brown
University, Providence, RI; she was at Case Western Reserve University at the time
this study was conducted
| | - David F. Warner
- Department of Sociology, University of Alabama at
Birmingham, Birmingham, AL
- Center for Family & Demographic Research, Bowling Green
State University, Bowling Green, OH
| | - Nicholas K. Schiltz
- Frances Payne Bolton School of Nursing, Case Western
Reserve University, Cleveland, OH
| | - Jennifer Cullen
- Department of Population and Quantitative Health Sciences,
Case Western Reserve University School of Medicine, Cleveland, OH
- Case Comprehensive Cancer Center, Case Western Reserve
University School of Medicine, Cleveland, OH
| | - Cynthia Owusu
- Case Comprehensive Cancer Center, Case Western Reserve
University School of Medicine, Cleveland, OH
- Department of Internal Medicine, University Hospitals
Cleveland Medical Center, Cleveland, OH
| | - Martha Sajatovic
- Department of Neurology, University Hospitals Cleveland
Medical Center, Cleveland, OH
| | - Johnie Rose
- Department of Population and Quantitative Health Sciences,
Case Western Reserve University School of Medicine, Cleveland, OH
- Case Comprehensive Cancer Center, Case Western Reserve
University School of Medicine, Cleveland, OH
- Center for Community Health Integration, School of
Medicine, Case Western Reserve University, Cleveland, OH
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Chen KX, Hsu PC, Lin JN, Lee FP, Wang JJ. Exploring the Difficulties and Strategies of Family Caregivers in Caring for Patients With Dementia in Acute Care Wards. J Nurs Res 2023; 31:e297. [PMID: 37548951 DOI: 10.1097/jnr.0000000000000575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Providing appropriate care to patients with dementia in acute care settings can be a challenge for healthcare professionals. A key factor is working closely with family caregivers. PURPOSE This study aims to explore the difficulties and strategies involved in caring for patients with dementia who have been admitted to an acute care ward from the perspective of family caregivers. METHODS Exploratory research was conducted using a qualitative data collection approach. Data were collected by means of in-depth interviews carried out with participants. Semistructured interviews were conducted with nine participants. Content analysis was performed to analyze the data. RESULTS A number of themes and subthemes were identified based on the primary research purposes. The first theme is "vicious cycle due to multiple factors," with the following subthemes: (a) communication disturbance, (b) endless worries, (c) inadequate care skills of paid caregivers, and (d) physical and psychological exhaustion. The second theme is "do everything," with the following subthemes: (a) management of the behavioral and psychological symptoms of dementia, (b) constant accompaniment of the patient, and (c) seeking sources of support. CONCLUSIONS/IMPLICATIONS FOR PRACTICE The results may be used to help healthcare professionals better anticipate the difficulties faced by family caregivers while providing assistance to patients with dementia and understand the related strategies they use. Acute care wards should consider the specific needs of family caregivers to ensure patients with dementia receive adequate care from the relevant parties in the ecological care chain during the care process.
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Affiliation(s)
- Ko-Xin Chen
- MS, RN, Doctoral Student, Department of Nursing, College of Medicine, National Cheng Kung University, Taiwan
| | - Pei-Chen Hsu
- MS, RN, Doctoral Student, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Taiwan
| | - Jong-Ni Lin
- PhD, RN, Assistant Professor, Department of Nursing, Da-Yeh University, Taiwan
| | - Feng-Ping Lee
- PhD, RN, Associate Professor, Department of Nursing, California State University, USA
| | - Jing-Jy Wang
- PhD, RN, Professor, Department of Nursing, College of Medicine, National Cheng Kung University, Taiwan
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10
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Toles M, Kistler C, Lin FC, Lynch M, Wessell K, Mitchell SL, Hanson LC. Palliative care for persons with late-stage Alzheimer's and related dementias and their caregivers: protocol for a randomized clinical trial. Trials 2023; 24:606. [PMID: 37743478 PMCID: PMC10518941 DOI: 10.1186/s13063-023-07614-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Limited access to specialized palliative care exposes persons with late-stage Alzheimer's disease and related dementias (ADRD) to burdensome treatment and unnecessary hospitalization and their caregivers to avoidable strain and financial burden. Addressing this unmet need, the purpose of this study was to conduct a randomized clinical trial (RCT) of the ADRD-Palliative Care (ADRD-PC) program. METHODS The study will use a multisite, RCT design and will be set in five geographically diverse US hospitals. Lead investigators and outcome assessors will be masked. The study will use 1:1 randomization of patient-caregiver dyads, and sites will enroll N = 424 dyads of hospitalized patients with late-stage ADRD with their family caregivers. Intervention dyads will receive the ADRD-PC program of (1) dementia-specific palliative care, (2) standardized caregiver education, and (3) transitional care. Control dyads will receive publicly available educational material on dementia caregiving. Outcomes will be measured at 30 days (interim) and 60 days post-discharge. The primary outcome will be 60-day hospital transfers, defined as visits to an emergency department or hospitalization ascertained from health record reviews and caregiver interviews (aim 1). Secondary patient-centered outcomes, ascertained from 30- and 60-day health record reviews and caregiver telephone interviews, will be symptom treatment, symptom control, use of community palliative care or hospice, and new nursing home transitions (aim 2). Secondary caregiver-centered outcomes will be communication about prognosis and goals of care, shared decision-making about hospitalization and other treatments, and caregiver distress (aim 3). Analyses will use intention-to-treat, and pre-specified exploratory analyses will examine the effects of sex as a biologic variable and the GDS stage. DISCUSSION The study results will determine the efficacy of an intervention that addresses the extraordinary public health impact of late-stage ADRD and suffering due to symptom distress, burdensome treatments, and caregiver strain. While many caregivers prioritize comfort in late-stage ADRD, shared decision-making is rare. Hospitalization creates an opportunity for dementia-specific palliative care, and the study findings will inform care redesign to advance comprehensive dementia-specific palliative care plus transitional care. TRIAL REGISTRATION ClinicalTrials.gov NCT04948866. Registered on July 2, 2021.
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Affiliation(s)
- M Toles
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - C Kistler
- Department of Family Medicine and Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - F C Lin
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M Lynch
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - K Wessell
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, and Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - L C Hanson
- Division of Geriatrics and Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Tingström P, Karlsson N, Grodzinsky E, Sund Levander M. The value of fever assessment in addition to the Early Detection Infection Scale (EDIS). A validation study in nursing home residents in Sweden. BMC Geriatr 2023; 23:585. [PMID: 37737163 PMCID: PMC10515033 DOI: 10.1186/s12877-023-04266-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 08/30/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND In order to improve detection of suspected infections in frail elderly there is an urgent need for development of decision support tools, that can be used in the daily work of all healthcare professionals for assessing non-specific and specific changes. The aim was to study non-specific signs and symptoms and fever temperature for early detection of ongoing infection in frail elderly, and how these correlates to provide the instrument, the Early Detection Infection Scale (EDIS), which is used to assess changes in health condition in frail elderly. METHODS This was an explorative, prospective cohort study, including 45 nursing home residents, 76 to 99 years, in Sweden. Nursing assistants measured morning ear body temperature twice a week and used the EDIS to assess individual health condition daily for six months. The outcome comprised events of suspected infection, compiled from nursing and medical patient records. Factor analysis and multivariate logistic regression analysis were performed to analyse data. RESULTS Fifteen residents were diagnosed with at least one infection during the six-month follow-up and 189 observations related to 72 events of suspected infection were recorded. The first factor analysis revealed that the components, change in cognitive and physical function, general signs and symptoms of illness, increased tenderness, change in eye expression and food intake and change in emotions explained 61% of the variance. The second factor analysis, adding temperature assessed as fever to > 1.0 °C from individual normal, resulted in change in physical function and food intake, confusion and signs and symptoms from respiratory and urinary tract, general signs and symptoms of illness and fever and increased tenderness, explaining 59% of the variance. In the first regression analysis, increased tenderness and change in eye expression and food intake, and in the second change in physical function and food intake, general signs and symptoms of illness and fever (> 1.0 °C from individual normal) and increased tenderness were significantly associated with increased risk for ongoing infection. CONCLUSION No items in the EDIS should be removed at present, and assessment of fever as > 1.0 °C from individual normal is a valuable addition. The EDIS has the potential to make it easier for first line caregivers to systematically assess changes in health condition in fragile elderly people and helps observations to be communicated in a standardised way throughout the care process. The EDIS thus contributes to ensuring that the decisions not being taken at the wrong level of care.
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Affiliation(s)
- Pia Tingström
- Medical Faculty, Linköping University, Linköping, Sweden.
| | | | - Ewa Grodzinsky
- Medical Faculty, Linköping University, Linköping, Sweden
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Powell KR, Popescu M, Lee S, Mehr DR, Alexander GL. Examining the Use of Text Messages Among Multidisciplinary Care Teams to Reduce Avoidable Hospitalization of Nursing Home Residents with Dementia: Protocol for a Secondary Analysis. JMIR Res Protoc 2023; 12:e50231. [PMID: 37556199 PMCID: PMC10448283 DOI: 10.2196/50231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Reducing avoidable nursing home (NH)-to-hospital transfers of residents with Alzheimer disease or a related dementia (ADRD) has become a national priority due to the physical and emotional toll it places on residents and the high costs to Medicare and Medicaid. Technologies supporting the use of clinical text messages (TMs) could improve communication among health care team members and have considerable impact on reducing avoidable NH-to-hospital transfers. Although text messaging is a widely accepted mechanism of communication, clinical models of care using TMs are sparsely reported in the literature, especially in NHs. Protocols for assessing technologies that integrate TMs into care delivery models would be beneficial for end users of these systems. Without evidence to support clinical models of care using TMs, users are left to design their own methods and protocols for their use, which can create wide variability and potentially increase disparities in resident outcomes. OBJECTIVE Our aim is to describe the protocol of a study designed to understand how members of the multidisciplinary team communicate using TMs and how salient and timely communication can be used to avert poor outcomes for NH residents with ADRD, including hospitalization. METHODS This project is a secondary analysis of data collected from a Centers for Medicare & Medicaid Services (CMS)-funded demonstration project designed to reduce avoidable hospitalizations for long-stay NH residents. We will use two data sources: (1) TMs exchanged among the multidisciplinary team across the 7-year CMS study period (August 2013-September 2020) and (2) an adapted acute care transfer tool completed by advanced practice registered nurses to document retrospective details about NH-to-hospital transfers. The study is guided by an age-friendly model of care called the 4Ms (What Matters, Medications, Mentation, and Mobility) framework. We will use natural language processing, statistical methods, and social network analysis to generate a new ontology and to compare communication patterns found in TMs occurring around the time NH-to-hospital transfer decisions were made about residents with and without ADRD. RESULTS After accounting for inclusion and exclusion criteria, we will analyze over 30,000 TMs pertaining to over 3600 NH-to-hospital transfers. Development of the 4M ontology is in progress, and the 3-year project is expected to run until mid-2025. CONCLUSIONS To our knowledge, this project will be the first to explore the content of TMs exchanged among a multidisciplinary team of care providers as they make decisions about NH-to-hospital resident transfers. Understanding how the presence of evidence-based elements of high-quality care relate to avoidable hospitalizations among NH residents with ADRD will generate knowledge regarding the future scalability of behavioral interventions. Without this knowledge, NHs will continue to rely on ineffective and outdated communication methods that fail to account for evidence-based elements of age-friendly care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50231.
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Affiliation(s)
- Kimberly R Powell
- Sinclair School of Nursing, University of Missouri, Columbia, MO, United States
| | - Mihail Popescu
- School of Medicine, University of Missouri, Columbia, MO, United States
| | - Suhwon Lee
- College of Arts and Sciences, University of Missouri, Columbia, MO, United States
| | - David R Mehr
- School of Medicine, University of Missouri, Columbia, MO, United States
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13
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Sakamoto A, Inokuchi R, Iwagami M, Sun Y, Tamiya N. Association between advanced care planning and emergency department visits: A systematic review. Am J Emerg Med 2023; 68:84-91. [PMID: 36958094 DOI: 10.1016/j.ajem.2023.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/16/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Advance care planning can help provide optimal medical care according to a patient's wishes as a part of patient-centered discussions on end-of-life care. This can prevent undesired transfers to emergency departments. However, the effects of advance care planning on emergency department visits and ambulance calls in various settings or specific conditions remain unclear. AIM To evaluate whether advanced care planning affected the frequency of emergency department visits and ambulance calls. DESIGN Systematic review. This study was registered in PROSPERO (CRD42022340109). We assessed risk of bias using RoB 2.0, ROBINS-I, and ROBINS-E. DATA SOURCES We searched the PubMed, Cochrane CENTRAL, and EMBASE databases from their inception until September 22, 2022 for studies comparing patients with and without advanced care planning and reported the frequency of emergency department visits and ambulance calls as outcomes. RESULTS Eight studies were included. Regarding settings, two studies on patients in nursing homes showed that advanced care planning significantly reduced the frequency of emergency department visits and ambulance calls. However, two studies involving several medical care facilities reported inconclusive results. Regarding patient disease, a study on patients with depression or dementia showed that advanced care planning significantly reduced emergency department visits; in contrast, two studies on patients with severe respiratory diseases and serious illnesses showed no significant reduction. Seven studies showed a high risk of bias. CONCLUSIONS Advanced care planning may lead to reduced emergency department visits and ambulance calls among nursing home residents and patients with depression or dementia. Further research is warranted to identify the effectiveness of advanced care planning in specific settings and diseases.
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Affiliation(s)
- Ayaka Sakamoto
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
| | - Ryota Inokuchi
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan.
| | - Masao Iwagami
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
| | - Yu Sun
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
| | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
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14
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Valk-Draad MP, Bohnet-Joschko S. [Nursing home-sensitive conditions and approaches to reduce hospitalization of nursing home residents]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:199-211. [PMID: 36625862 PMCID: PMC9830609 DOI: 10.1007/s00103-022-03654-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Interventions to reduce potentially risky hospitalizations among nursing home residents are highly relevant for patient safety and quality improvement. A catalog of nursing home-sensitive conditions (NHSCs) grounds the policy recommendations and interventions. METHODS In two previous research phases, an expert panel developed a catalog of 58 NHSCs using an adapted Delphi-procedure (the RAND/UCLA Appropriateness Method). This procedure was developed by the North American non-profit Research and Development Organisation (RAND) and clinicians of the University of California in Los Angeles (UCLA). We present the third phase of the project focused on the development of interventions to reduce NHSCs starting with an expert workshop. The workshop results were then evaluated by six experts from related sectors, supplemented, and systematically used to produce recommendations for action. Possible implementation obstacles were considered and the time horizon of effectiveness was estimated. RESULTS The recommendations address communication, cooperation, documentation and care competence as well as facility-related, financial, and legal aspects. Indication bundles demonstrate the relevance for the German healthcare system. To increase effectiveness, the experts advise a meaningful combination of individual recommendations. DISCUSSION By optimizing multidisciplinary communication and cooperation, combined with an- also digital - expansion of the infrastructure and the creation of institution-specific and legal prerequisites as well as remuneration structures, an estimated 35% of all hospitalizations, approximately 220,000 hospitalizations for Germany, could be prevented. The implementation expenditure could be refinanced by avoided hospitalization savings amounting to 768 million euros.
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Affiliation(s)
- Maria Paula Valk-Draad
- Lehrstuhl für Management und Innovation im Gesundheitswesen, Fakultät für Wirtschaft und Gesellschaft, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Deutschland
- Lehrstuhl für Community Health Nursing, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Deutschland
| | - Sabine Bohnet-Joschko
- Lehrstuhl für Management und Innovation im Gesundheitswesen, Fakultät für Wirtschaft und Gesellschaft, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Deutschland.
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15
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[Reasons for hospitalization of people with dementia-A scoping review]. Z Gerontol Geriatr 2023; 56:42-47. [PMID: 35420353 PMCID: PMC9876850 DOI: 10.1007/s00391-021-02013-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/28/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hospitalization represents a high burden for people with dementia, which can accelerate the decline of cognitive and motor skills. Behavioral changes and orientation problems may be increased in people with dementia during hospitalization. Some hospitalizations are potentially preventable by improved outpatient care. OBJECTIVE To provide an up to date overview of the most common reasons for hospitalization of people with dementia or mild cognitive impairment. MATERIAL AND METHODS A systematic literature search was conducted in the databases PubMed®, CINAHL and PsycINFO® in May 2020 to conduct the scoping review. Studies in German and English published between July 2010 and May 2020 were included. RESULTS The most common reasons for hospitalization, which were named in the 14 included studies, were infectious diseases, especially respiratory infections and urinary tract infections, cardiovascular diseases (in general or specific, e.g. heart failure) and injuries, poisoning, fractures and falls, and gastrointestinal diseases. CONCLUSION Most of the most common reasons for hospitalization are ambulatory care-sensitive hospital cases. Strengthening outpatient care for people with dementia may help prevent hospitalizations.
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16
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Aryal K, Mowbray FI, Strum RP, Dash D, Tanuseputro P, Heckman G, Costa AP, Jones A. Examining the "Potentially Preventable Emergency Department Transfer" Indicator Among Nursing Home Residents. J Am Med Dir Assoc 2023; 24:100-104.e2. [PMID: 36379265 DOI: 10.1016/j.jamda.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine if nursing home (NH) resident characteristics associated with potentially preventable emergency department transfers (PPEDs) are similarly associated with non-potentially preventable emergency department transfers (non-PPEDs). DESIGN We conducted a population-level retrospective cohort study using linked administrative data reported using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and the National Ambulatory Care Reporting System for emergency department transfers. SETTING AND PARTICIPANTS We assessed all NH residents transferred to the emergency department within 92 days after admission. The cohort included 56,433 NH resident admissions assessment of which 3498 NH residents experienced PPEDs, and 9331 residents experienced non-PPEDs. METHODS We assessed Ontario NH residents admission assessments collected between January 1, 2017, and December 31, 2018. We used cumulative incidence functions and Cox regression to compare resident characteristics between residents experiencing PPEDs and non-PPEDs. PPEDs were defined based on the International Classification of Diseases, 10th Revision. RESULTS Approximately 23% of residents experienced an emergency department transfer within 92 days of NH admission. The cumulative incidence of PPEDs was 6.3% and non-PPEDs was 16.8%. After adjusting for clinically relevant features, 14 of 18 resident admission characteristics were associated with both types of transfers. Resident admission characteristics associated with a greater risk of PPEDs solely were pneumonia [hazard ratio (HR) 1.48; CI 1.25-1.70] and oxygen therapy (HR 1.88; CI 1.69-2.10). Resident admission characteristics associated with a greater risk of non-PPEDs solely are experiencing a change in mood (HR 1.09; CI 1.01-1.18) and delirium (HR 1.08; CI 1.04-1.13). CONCLUSIONS AND IMPLICATIONS PPEDs were associated with a similar cluster of NH resident characteristics as those transferred for non-ambulatory reasons, suggesting that the clinical distinction between PPEDs vs non-PPEDs within the NH might be unclear. These findings highlight that the PPED indicator could be revised to improve specificity.
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Affiliation(s)
- Komal Aryal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Ryan P Strum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Peter Tanuseputro
- ICES, Toronto, Ontario, Canada; Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - George Heckman
- Schlegel Research Chair in Geriatric Medicine, Schlegel Research Institute for Aging, Waterloo, Ontario, Canada; School of Public Health Sciences, University of Waterloo, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
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17
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Hickman SE, Mitchell SL, Hanson LC, Tu W, Stump TE, Unroe KT. The design and conduct of a pragmatic cluster randomized trial of an advance care planning program for nursing home residents with dementia. Clin Trials 2022; 19:623-635. [PMID: 35815777 PMCID: PMC9691516 DOI: 10.1177/17407745221108992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS A significant number of people with Alzheimer's disease or related dementia diagnoses will be cared for in nursing homes near the end of life. Advance care planning (ACP), the process of eliciting and documenting patient-centered preferences for care, is considered essential to providing high quality care for this population. Nursing homes are currently required by regulations to offer ACP to residents and families, but no training requirements exist for nursing home staff, and approaches to fulfilling this regulatory and ethical responsibility vary. As a result, residents may receive care inconsistent with their goals, such as unwanted hospitalizations. Pragmatic trials offer a way to develop and test ACP in real-world settings to increase the likelihood of adoption of sustainable best practices. METHODS The "Aligning Patient Preferences-a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support (APPROACHES)" project is designed to pragmatically test and evaluate a staff-led program in 137 nursing homes (68 = intervention, 69 = control) owned by two nursing home corporations. Existing nursing home staff receive standardized training and implement the ACP Specialist program under the supervision of a corporate lead. The primary trial outcome is the annual rate of hospital transfers (admissions and emergency department visits). Consistent with the spirit of a pragmatic trial, study outcomes rely on data already collected for quality improvement, clinical, or billing purposes. Configurational analysis will also be performed to identify conditions associated with implementation. RESULTS Partnerships with large corporate companies enable the APPROACHES trial to rely on corporate infrastructure to roll out the intervention, with support for a corporate implementation lead who is charged with the initial introduction and ongoing support for nursing home-based ACP Specialists. These internal champions connect the project with other company priorities and use strategies familiar to nursing home leaders for the initiation of other programs. Standardized data collection across nursing homes also supports the conduct of pragmatic trials in this setting. DISCUSSION Many interventions to improve care in nursing homes have failed to demonstrate an impact or, if successful, maintain an impact over time. Pragmatic trials, designed to test interventions in real-world contexts that are evaluated through existing data sources collected routinely as part of clinical care, are well suited for the nursing home environment. A robust program that increases access to ACP for nursing home residents has the potential to increase goal-concordant care and is expected to reduce hospital transfers. If successful, the ACP Specialist Program will be primed for rapid translation into nursing home practice to reduce unwanted, burdensome hospitalizations and improve the quality of care for residents with dementia.
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Affiliation(s)
- Susan E Hickman
- School of Nursing, Indiana University, Indianapolis,
Indiana, U.S.,RESPECT (Research in Palliative and End-of-Life
Communication and Training) Signature Center, Indiana University Purdue University
Indianapolis, Indianapolis, Indiana, U.S.,Division of General Internal Medicine and Geriatrics, Department of Medicine, School of Medicine, Indiana University, Indiana, U.S.,IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S
| | - Susan L Mitchell
- Harvard Medical School, Boston, Massachusetts, U.S.,Beth Israel Deaconess Medical Center, Boston,
Massachusetts, U.S.,Marcus Institute for Aging Research, Boston, Massachusetts,
U.S
| | - Laura C Hanson
- School of Medicine, University of North Carolina, Chapel Hill,
North Carolina
| | - Wanzhu Tu
- IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S.,Department of Biostatistics & Health Data ScienceS, School of Medicine,
Indiana University, Indiana, U.S
| | - Timothy E Stump
- Department of Biostatistics & Health Data ScienceS, School of Medicine,
Indiana University, Indiana, U.S
| | - Kathleen T Unroe
- RESPECT (Research in Palliative and End-of-Life
Communication and Training) Signature Center, Indiana University Purdue University
Indianapolis, Indianapolis, Indiana, U.S.,Division of General Internal Medicine and Geriatrics, Department of Medicine, School of Medicine, Indiana University, Indiana, U.S.,IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S
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18
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Just and inclusive end-of-life decision-making for long-term care home residents with dementia: a qualitative study protocol. BMC Palliat Care 2022; 21:202. [PMID: 36419147 PMCID: PMC9684772 DOI: 10.1186/s12904-022-01097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Many people living with dementia eventually require care services and spend the remainder of their lives in long-term care (LTC) homes. Yet, many residents with dementia do not receive coordinated, quality palliative care. The stigma associated with dementia leads to an assumption that people living in the advanced stages of dementia are unable to express their end-of-life needs. As a result, people with dementia have fewer choices and limited access to palliative care. The purpose of this paper is to describe the protocol for a qualitative study that explores end-of-life decision-making processes for LTC home residents with dementia. METHODS/DESIGN This study is informed by two theoretical concepts. First, it draws on a relational model of citizenship. The model recognizes the pre-reflective dimensions of agency as fundamental to being human (irrespective of cognitive impairment) and thereby necessitates that we cultivate an environment that supports these dimensions. This study also draws from Smith's critical feminist lens to foreground the influence of gender relations in decision-making processes towards palliative care goals for people with dementia and reveal the discursive mediums of power that legitimize and sanction social relations. This study employs a critical ethnographic methodology. Through data collection strategies of interview, observation, and document review, this study examines decision-making for LTC home residents with dementia and their paid (LTC home workers) and unpaid (family members) care partners. DISCUSSION This research will expose the embedded structures and organizational factors that shape relationships and interactions in decision-making. This study may reveal new ways to promote equitable decision-making towards palliative care goals for LTC home residents with dementia and their care partners and help to improve their access to palliative care.
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Wang X, Ezeana CF, Wang L, Puppala M, Huang Y, He Y, Yu X, Yin Z, Zhao H, Lai EC, Wong STC. Risk factors and machine learning model for predicting hospitalization outcomes in geriatric patients with dementia. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2022; 8:e12351. [PMID: 36204350 PMCID: PMC9520763 DOI: 10.1002/trc2.12351] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/26/2022]
Abstract
Introduction Geriatric patients with dementia incur higher healthcare costs and longer hospital stays than other geriatric patients. We aimed to identify risk factors for hospitalization outcomes that could be mitigated early to improve outcomes and impact overall quality of life. Methods We identified risk factors, that is, demographics, hospital complications, pre-admission, and post-admission risk factors including medical history and comorbidities, affecting hospitalization outcomes determined by hospital stays and discharge dispositions. Over 150 clinical and demographic factors of 15,678 encounters (8407 patients) were retrieved from our institution's data warehouse. We further narrowed them down to twenty factors through feature selection engineering by using analysis of variance (ANOVA) and Glmnet. We developed an explainable machine-learning model to predict hospitalization outcomes among geriatric patients with dementia. Results Our model is based on stacking ensemble learning and achieved accuracy of 95.6% and area under the curve (AUC) of 0.757. It outperformed prevalent methods of risk assessment for encounters of patients with Alzheimer's disease dementia (ADD) (4993), vascular dementia (VD) (4173), Parkinson's disease with dementia (PDD) (3735), and other unspecified dementias (OUD) (2777). Top identified hospitalization outcome risk factors, mostly from medical history, include encephalopathy, number of medical problems at admission, pressure ulcers, urinary tract infections, falls, admission source, age, race, anemia, etc., with several overlaps in multi-dementia groups. Discussion Our model identified several predictive factors that can be modified or intervened so that efforts can be made to prevent recurrence or mitigate their adverse effects. Knowledge of the modifiable risk factors would help guide early interventions for patients at high risk for poor hospitalization outcome as defined by hospital stays longer than seven days, undesirable discharge disposition, or both. The interventions include starting specific protocols on modifiable risk factors like encephalopathy, falls, and infections, where non-existent or not routine, to improve hospitalization outcomes of geriatric patients with dementia. Highlights A total 15,678 encounters of Geriatrics with dementia with a final 20 risk factors.Developed a predictive model for hospitalization outcomes for multi-dementia types.Risk factors for each type were identified including those amenable to interventions.Top factors are encephalopathy, pressure ulcers, urinary tract infection (UTI), falls, and admission source.With accuracy of 95.6%, our ensemble predictive model outperforms other models.
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Affiliation(s)
- Xin Wang
- T.T. & W.F. Chao Center for BRAINHouston Methodist Academic InstituteHouston Methodist HospitalHoustonTexasUSA
| | - Chika F. Ezeana
- T.T. & W.F. Chao Center for BRAINHouston Methodist Academic InstituteHouston Methodist HospitalHoustonTexasUSA
| | - Lin Wang
- T.T. & W.F. Chao Center for BRAINHouston Methodist Academic InstituteHouston Methodist HospitalHoustonTexasUSA
| | - Mamta Puppala
- T.T. & W.F. Chao Center for BRAINHouston Methodist Academic InstituteHouston Methodist HospitalHoustonTexasUSA
| | | | - Yunjie He
- T.T. & W.F. Chao Center for BRAINHouston Methodist Academic InstituteHouston Methodist HospitalHoustonTexasUSA
| | - Xiaohui Yu
- T.T. & W.F. Chao Center for BRAINHouston Methodist Academic InstituteHouston Methodist HospitalHoustonTexasUSA
| | - Zheng Yin
- T.T. & W.F. Chao Center for BRAINHouston Methodist Academic InstituteHouston Methodist HospitalHoustonTexasUSA
| | - Hong Zhao
- T.T. & W.F. Chao Center for BRAINHouston Methodist Academic InstituteHouston Methodist HospitalHoustonTexasUSA
| | - Eugene C. Lai
- Neurological InstituteHouston Methodist HospitalHoustonTexasUSA
| | - Stephen T. C. Wong
- T.T. & W.F. Chao Center for BRAINHouston Methodist Academic InstituteHouston Methodist HospitalHoustonTexasUSA
- Brain and Mind Research InstituteWeill Cornell Medical CollegeNew YorkUSA
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20
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Brucki SMD, Aprahamian I, Borelli WV, Silveira VCD, Ferretti CEDL, Smid J, Barbosa BJAP, Schilling LP, Balthazar MLF, Frota NAF, Souza LCD, Vale FAC, Caramelli P, Bertolucci PHF, Chaves MLF, Nitrini R, Schultz RR, Morillo LS. Management in severe dementia: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Dement Neuropsychol 2022. [DOI: 10.1590/1980-5764-dn-2022-s107en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
ABSTRACT Alzheimer’s disease (AD) and other neurodegenerative dementias have a progressive course, impairing cognition, functional capacity, and behavior. Most studies have focused on AD. Severe dementia is associated with increased age, higher morbidity-mortality, and rising costs of care. It is fundamental to recognize that severe dementia is the longest period of progression, with patients living for many years in this stage. It is the most heterogeneous phase in the process, with different abilities and life expectancies. This practice guideline focuses on severe dementia to improve management and care in this stage of dementia. As it is a long period in the continuum of dementia, clinical practice should consider non-pharmacological and pharmacological approaches. Multidisciplinary interventions (physical therapy, speech therapy, nutrition, nursing, and others) are essential, besides educational and support to caregivers.
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Affiliation(s)
| | - Ivan Aprahamian
- Faculdade de Medicina de Jundiaí, Brasil; University of Groningen, The Netherlands; Universidade de São Paulo, Brasil
| | | | | | | | | | - Breno José Alencar Pires Barbosa
- Universidade de São Paulo, Brazil; Universidade Federal de Pernambuco, Brasil; Instituto de Medicina Integral Prof. Fernando Figueira, Brasil
| | - Lucas Porcello Schilling
- Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil
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Brucki SMD, Aprahamian I, Borelli WV, Silveira VCD, Ferretti CEDL, Smid J, Barbosa BJAP, Schilling LP, Balthazar MLF, Frota NAF, Souza LCD, Vale FAC, Caramelli P, Bertolucci PHF, Chaves MLF, Nitrini R, Schultz RR, Morillo LS. Manejo das demências em fase avançada: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Dement Neuropsychol 2022; 16:101-120. [DOI: 10.1590/1980-5764-dn-2022-s107pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/04/2021] [Accepted: 04/27/2022] [Indexed: 11/29/2022] Open
Abstract
RESUMO A doença de Alzheimer (DA) e outras demências neurodegenerativas têm um curso progressivo com comprometimento da cognição, capacidade funcional e comportamento. A maioria dos estudos enfocou a DA. A demência grave está associada ao aumento da idade, maior morbimortalidade e aumento dos custos de cuidados. É fundamental reconhecer que a demência grave é o período mais longo de progressão, com o paciente vivendo muitos anos nesta fase. É a fase mais heterogênea do processo, com diferentes habilidades e expectativa de vida. Esta diretriz de prática concentra-se na demência grave para melhorar o manejo e o cuidado nessa fase da demência. Como um longo período no continuum da demência, as abordagens não farmacológicas e farmacológicas devem ser consideradas. Intervenções multidisciplinares (fisioterapia, fonoaudiologia, nutrição, enfermagem, entre outras) são essenciais, além de educacionais e de apoio aos cuidadores.
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Affiliation(s)
| | - Ivan Aprahamian
- Faculdade de Medicina de Jundiaí, Brasil; University of Groningen, The Netherlands; Universidade de São Paulo, Brasil
| | | | | | | | | | - Breno José Alencar Pires Barbosa
- Universidade de São Paulo, Brazil; Universidade Federal de Pernambuco, Brasil; Instituto de Medicina Integral Prof. Fernando Figueira, Brasil
| | - Lucas Porcello Schilling
- Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil
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22
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McKenna G, Tsakos G, Watson S, Jenkins A, Algar PM, Evans R, Baker SR, Chestnutt IG, Smith CJ, O'Neill C, Hoare Z, Williams L, Jones V, Donaldson M, Karki A, Lappin C, Moons K, Sandom F, Wimbury M, Morgan L, Shepherd K, Brocklehurst P. uSing rolE-substitutioN In care homes to improve ORal health (SENIOR): a study protocol. Trials 2022; 23:679. [PMID: 35982457 PMCID: PMC9386206 DOI: 10.1186/s13063-022-06487-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Dental service provision in the care home sector is poor, with little emphasis on prevention. Emerging evidence suggests that the use of Dental Care Professionals (dental therapists and dental nurses) as an alternative to dentists has the potential to improve preventive advice, the provision of care and access to services within care homes. However, robust empirical evidence from definitive trials on how to successfully implement and sustain these interventions within care homes is currently lacking. The aim of the study is to determine whether Dental Care Professionals could reduce plaque levels of dentate older adults (65 + years) residing in care homes. Methods This protocol describes a two-arm cluster-randomised controlled trial that will be undertaken in care homes across Wales, Northern Ireland and England. In the intervention arm, the dental therapists will visit the care homes every 6 months to assess and then treat eligible residents, where necessary. All treatment will be conducted within their Scope of Practice. Dental nurses will visit the care homes every month for the first 3 months and then three-monthly afterwards to promulgate advice to improve the day-to-day prevention offered to residents by carers. The control arm will be ‘treatment as usual’. Eligible care homes (n = 40) will be randomised based on a 1:1 ratio (20 intervention and 20 control), with an average of seven residents recruited in each home resulting in an estimated sample of 280. Assessments will be undertaken at baseline, 6 months and 12 months and will include a dental examination and quality of life questionnaires. Care home staff will collect weekly information on the residents’ oral health (e.g. episodes of pain and unscheduled care). The primary outcome will be a binary classification of the mean reduction in Silness-Löe Plaque Index at 6 months. A parallel process evaluation will be undertaken to explore the intervention’s acceptability and how it could be embedded in standard practice (described in a separate paper), whilst a cost-effectiveness analysis will examine the potential long-term costs and benefits of the intervention. Discussion This trial will provide evidence on how to successfully implement and sustain a Dental Care Professional-led intervention within care homes to promote access and prevention. Trial registration ISRCTN16332897. Registered on 3 December 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06487-3.
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Affiliation(s)
- Gerald McKenna
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Institute of Clinical Science Block A, Belfast, BT12 6BA, UK
| | - Georgios Tsakos
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Sinead Watson
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Institute of Clinical Science Block A, Belfast, BT12 6BA, UK.
| | - Alison Jenkins
- NWORTH Clinical Trials Unit, Bangor University, Bangor, UK
| | | | - Rachel Evans
- NWORTH Clinical Trials Unit, Bangor University, Bangor, UK
| | - Sarah R Baker
- Unit of Oral Health, Dentistry and Society, University of Sheffield, Sheffield, UK
| | - Ivor G Chestnutt
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Craig J Smith
- Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK.,Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation NHS Trust, Salford, UK
| | - Ciaran O'Neill
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Institute of Clinical Science Block A, Belfast, BT12 6BA, UK
| | - Zoe Hoare
- NWORTH Clinical Trials Unit, Bangor University, Bangor, UK
| | - Lynne Williams
- School of Health Sciences, Bangor University, Bangor, UK
| | - Vicki Jones
- Community Dental Services, Aneurin Bevan University Health Board, Newport, UK
| | | | | | - Caroline Lappin
- Community Dental Service, South Eastern Health and Social Care Trust, Dundonald, UK
| | - Kirstie Moons
- Health Education and Improvement Wales, Nantgarw, UK
| | - Fiona Sandom
- Health Education and Improvement Wales, Nantgarw, UK
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23
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Hendricksen M, Mitchell SL, Lopez RP, Mazor KM, McCarthy EP. Facility Characteristics Associated With Intensity of Care of Nursing Homes and Hospital Referral Regions. J Am Med Dir Assoc 2022; 23:1367-1374. [PMID: 34826394 PMCID: PMC9124728 DOI: 10.1016/j.jamda.2021.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/20/2021] [Accepted: 10/23/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Intensity of care, such as hospital transfers and tube feeding of residents with advanced dementia varies by nursing home (NH) within and across regions. Little work has been done to understand how these 2 levels of influence relate. This study's objectives are to identify facility factors associated with NHs providing high-intensity care to residents with advanced dementia and determine whether these factors differ within and across hospital referral regions (HRRs). DESIGN Cross-sectional analysis. SETTING AND PARTICIPANTS 1449 NHs. METHODS Nationwide 2016-2017 Minimum Data Set was used to categorize NHs and HRRs into 4 levels of care intensity based on rates of hospital transfers and tube feeding among residents with advanced dementia: low-intensity NH in a low-intensity HRR, high-intensity NH in a low-intensity HRR, low-intensity NH in a high-intensity HRR, and a high-intensity NH in a high-intensity HRR. RESULTS In high-intensity HRRs, high-vs low-intensity NHs were more likely to be urban, lack a dementia unit, have a nurse practitioner or physician (NP or PA) on staff, and have a higher proportion of residents who were male, aged <65 years, Black, had pressure ulcers, and shorter hospice stays. In low-intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high-intensity NH. CONCLUSIONS AND IMPLICATIONS These findings suggest that within high-intensity HRRs, there are potentially modifiable factors that could be targeted to reduce burdensome care in advanced dementia, including having a dementia unit, palliative care training for NPs and PAs, and increased use of hospice care.
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Affiliation(s)
- Meghan Hendricksen
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, MA, USA; Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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24
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Masot O, Cox A, Mold F, Sund-Levander M, Tingström P, Boersema GC, Botigué T, Daltrey J, Hughes K, Mayhorn CB, Montgomery A, Mullan J, Carey N. Decision support-tools for early detection of infection in older people (aged> 65 years): a scoping review. BMC Geriatr 2022; 22:552. [PMID: 35778707 PMCID: PMC9247966 DOI: 10.1186/s12877-022-03218-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 05/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background Infection is more frequent, and serious in people aged > 65 as they experience non-specific signs and symptoms delaying diagnosis and prompt treatment. Monitoring signs and symptoms using decision support tools (DST) is one approach that could help improve early detection ensuring timely treatment and effective care. Objective To identify and analyse decision support tools available to support detection of infection in older people (> 65 years). Methods A scoping review of the literature 2010–2021 following Arksey and O’Malley (2005) framework and PRISMA-ScR guidelines. A search of MEDLINE, Cochrane, EMBASE, PubMed, CINAHL, Scopus and PsycINFO using terms to identify decision support tools for detection of infection in people > 65 years was conducted, supplemented with manual searches. Results Seventeen papers, reporting varying stages of development of different DSTs were analysed. DSTs largely focussed on specific types of infection i.e. urine, respiratory, sepsis and were frequently hospital based (n = 9) for use by physicians. Four DSTs had been developed in nursing homes and one a care home, two of which explored detection of non- specific infection. Conclusions DSTs provide an opportunity to ensure a consistent approach to early detection of infection supporting prompt action and treatment, thus avoiding emergency hospital admissions. A lack of consideration regarding their implementation in practice means that any attempt to create an optimal validated and tested DST for infection detection will be impeded. This absence may ultimately affect the ability of the workforce to provide more effective and timely care, particularly during the current covid-19 pandemic. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03218-w.
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Affiliation(s)
- Olga Masot
- Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain. .,Health Care Research Group (GRECS), [Lleida Institute for Biomedical Research Dr. Pifarré Foundation], IRBLleida, 25198, Lleida, Spain.
| | - Anna Cox
- School of Health Sciences, University of Surrey, Guildford, GU2 7YH, UK
| | - Freda Mold
- School of Health Sciences, University of Surrey, Guildford, GU2 7YH, UK
| | - Märtha Sund-Levander
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Pia Tingström
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Teresa Botigué
- Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain.,Health Care Research Group (GRECS), [Lleida Institute for Biomedical Research Dr. Pifarré Foundation], IRBLleida, 25198, Lleida, Spain
| | - Julie Daltrey
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Karen Hughes
- School of Health Sciences, University of Surrey, Guildford, GU2 7YH, UK
| | - Christopher B Mayhorn
- Department of Psychology, North Carolina State University, Raleigh, NC, 27695-7801, USA
| | - Amy Montgomery
- School of Nursing, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Judy Mullan
- School of Medicine, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Nicola Carey
- Department of Nursing and Midwifery, University of the Highlands and Islands, Inverness, IV2 3JH, UK
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25
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Harrad-Hyde F, Armstrong N, Williams CD. 'Weighing up risks': a model of care home staff decision-making about potential resident hospital transfers. Age Ageing 2022; 51:6649130. [PMID: 35871419 PMCID: PMC9308989 DOI: 10.1093/ageing/afac171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 05/16/2022] [Indexed: 11/14/2022] Open
Abstract
Background care home staff play a crucial role in managing residents’ health and responding to deteriorations. When deciding whether to transfer a resident to hospital, a careful consideration of the potential benefits and risks is required. Previous studies have identified factors that influence staff decision-making, yet few have moved beyond description to produce a conceptual model of the decision-making process. Objectives to develop a conceptual model to describe care home staff’s decision-making when faced with a resident who potentially requires a transfer to the hospital. Methods data collection occurred in England between May 2018 and November 2019, consisting of 28 semi-structured interviews with 30 members of care home staff across six care home sites and 113 hours of ethnographic observations, documentary analysis and informal conversations (with staff, residents, visiting families, friends and healthcare professionals) at three of these sites. Results a conceptual model of care home staff’s decision-making is presented. Except in situations that staff perceived to be urgent enough to require an immediate transfer, resident transfers tended to occur following a series of escalations. Care home staff made complex decisions in which they sought to balance a number of potential benefits and risks to: residents; staff (as decision-makers); social relationships; care home organisations and wider health and social care services. Conclusions during transfer decisions, care home staff make complex decisions in which they weigh up several forms of risk. The model presented offers a theoretical basis for interventions to support deteriorating care home residents and the staff responsible for their care.
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Affiliation(s)
- Fawn Harrad-Hyde
- Department of Health Sciences, George Davies Centre, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Natalie Armstrong
- Department of Health Sciences, George Davies Centre, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Christopher D Williams
- Department of Health Sciences, George Davies Centre, University of Leicester, University Road, Leicester, LE1 7RH, UK
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26
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Vogelsmeier A, Popejoy L, Fritz E, Canada K, Ge B, Brandt L, Rantz M. Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity. BMC Health Serv Res 2022; 22:626. [PMID: 35538575 PMCID: PMC9087933 DOI: 10.1186/s12913-022-08036-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers. Methods This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described. Results Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable. Conclusions Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.
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Affiliation(s)
- Amy Vogelsmeier
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.
| | - Lori Popejoy
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Elizabeth Fritz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Kelli Canada
- School of Social Work, University of Missouri, Columbia, MO, USA
| | - Bin Ge
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Lea Brandt
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Marilyn Rantz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
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27
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Goss A, O'Riordan DL, Pantilat S. Inpatients With Dementia Referred for Palliative Care Consultation: A Multicenter Analysis. Neurol Clin Pract 2022; 12:288-297. [DOI: 10.1212/cpj.0000000000001168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/14/2022] [Indexed: 11/15/2022]
Abstract
Background and Objectives:Specialty palliative care (PC) may benefit patients with dementia by aligning treatment with goals and relieving symptoms. We aimed to compare demographics and processes and outcomes of PC for inpatients with dementia to those with systemic illnesses or cancer.Methods:This multicenter cohort study included standardized data for hospitalized patients with a primary diagnosis of dementia, systemic illnesses (cardiovascular, pulmonary, hepatic, renal disease) or cancer among the 98 PC teams submitting data to the Palliative Care Quality Network from 2013-2019.Results:Out of 155,356 patients, 4.5% (n= 6,925) had a primary diagnosis of dementia, 32.5% (n=50,501) systemic illness, and 29.2% (n=45,386) cancer. Patients with dementia were older (mean 85.5 years, 95%CI 85.3-85.6) than those with systemic illnesses (mean 73.2, 95%CI 73.0-73.3) or cancer (mean 66.6, 95%CI 66.4-66.7; p<0.0001). Patients with dementia were more likely to receive a PC consult within 24 hours of admission (52.3% vs. systemic illnesses 37.4%; cancer 45.3%; p<0.0001), more likely to be bed-bound (vs. systemic illnesses OR 2.23, 95%CI 2.09-2.39, p<0.0001; vs. cancer OR 3.45, 95%CI 3.21-3.72, p<0.0001) and more likely to be discharged alive (vs. systemic illnesses OR 2.22, 95%CI 2.03-2.43, p<0.0001; vs. cancer OR 1.51, 95%CI 1.36-1.67, p<0.0001). Advance care planning / Goals of care (GOC) was the primary reason for consultation for all groups. Few patients overall had advance directives or Physician Orders for Life-Sustaining Treatment (POLSTs) prior to consultation. At the time of referral and at discharge, patients with dementia were more likely to have a code status of DNR/DNI (62.6% and 81.0% vs. 38.7 and 64.2% for patients with systemic illnesses, and 33.4% and 60.5% for patients with cancer; p<0.0001). Among the minority of patients with dementia that could self-report, moderate-to-severe symptoms were uncommon (pain 6.4%, anxiety 5.8%, nausea 0.4%, dyspnea 3.5%).Discussion:Inpatients with a primary diagnosis of dementia receiving PC consultation were older and more functionally impaired than those with other illnesses. They were more likely to have a code status of DNR/DNI at discharge. Few reported distressing symptoms. These results highlight the need for routine clarification of GOC for patients with dementia.
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Harrad-Hyde F, Armstrong N, Williams C. Using advance and emergency care plans during transfer decisions: A grounded theory interview study with care home staff. Palliat Med 2022; 36:200-207. [PMID: 34866482 PMCID: PMC8796154 DOI: 10.1177/02692163211059343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Advance care planning has been identified as one of few modifiable factors that could reduce hospital transfers from care homes. Several types of documents may be used by patients and clinicians to record these plans. However, little is known about how plans are perceived and used by care home staff at the time of deterioration. AIM To describe care home staff experiences and perceptions of using written plans during in-the-moment decision-making about potential resident hospital transfers. DESIGN Qualitative semi-structured interviews analysed using the Straussian approach to grounded theory. SETTING/PARTICIPANTS Thirty staff across six care homes (with and without nursing) in the East and West Midlands of England. RESULTS Staff preferred (in principle) to keep deteriorating residents in the care home but feared that doing so could lead to negative repercussions for them as individuals, especially when there was perceived discordance with family carers' wishes. They felt that clinicians should be responsible for these plans but were happy to take a supporting role. At the time of deterioration, written plans legitimised the decision to care for the resident within the home; however, staff were wary of interpreting broad statements and wanted plans to be detailed, specific, unambiguous, technically 'correct', understood by families and regularly updated. CONCLUSIONS Written plans provide reassurance for care home staff, reducing concerns about personal and professional risk. However, care home staff have limited discretion to interpret plans and transfers may occur if plans are not specific enough for care home staff to use confidently.
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Affiliation(s)
- Fawn Harrad-Hyde
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Natalie Armstrong
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Chris Williams
- Department of Health Sciences, University of Leicester, Leicester, UK
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29
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Aryal K, Mowbray F, Gruneir A, Griffith LE, Howard M, Jabbar A, Jones A, Tanuseputro P, Lapointe-Shaw L, Costa AP. Nursing Home Resident Admission Characteristics and Potentially Preventable Emergency Department Transfers. J Am Med Dir Assoc 2021; 23:1291-1296. [PMID: 34919839 DOI: 10.1016/j.jamda.2021.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To determine which nursing home (NH) resident-level admission characteristics are associated with potentially preventable emergency department (PPED) transfers. DESIGN We conducted a population-level retrospective cohort study on NH resident data collected using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and linked to the National Ambulatory Care Reporting System for ED transfers. SETTING We used all NH resident admission assessments from January 1, 2017, to December 31, 2018, in Ontario. PARTICIPANTS The cohort included the admission assessment of 56,433 NH residents. METHODS PPED transfers were defined based on the International Classification of Disease, Version 10 (Canadian) We used logistic regression with 10-fold cross-validation and computed average marginal effects to identify the association between resident characteristics at NH admission and PPED transfers within 92 days after admission. RESULTS Overall, 6.2% of residents had at least 1 PPED transfer within 92 days of NH admission. After adjustment, variables that had a prevalence of 10% or more that were associated with a 1% or more absolute increase in the risk of a PPED transfer included polypharmacy [of cohort (OC) 84.4%, risk difference (RD) 2.0%], congestive heart failure (OC 29.0%, RD 3.0%), and renal failure (OC 11.6%, RD 1.2%). Female sex (OC 63.2%, RD -1.3%), a do not hospitalize directive (OC 24.4%, RD -2.6%), change in mood (OC 66.9%, RD -1.2%), and Alzheimer's or dementia (OC 62.1%, RD -1.2%) were more than 10% prevalent and associated with a 1% or more absolute decrease in the risk of a PPED. CONCLUSIONS AND IMPLICATIONS Though many routinely collected resident characteristics were associated with a PPED transfer, the absence of sufficiently discriminating characteristics suggests that emergency department visits by NH residents are multifactorial and difficult to predict. Future studies should assess the clinical utility of risk factor identification to prevent transfers.
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Affiliation(s)
- Komal Aryal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Fabrice Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Andrea Gruneir
- ICES, Toronto, Ontario, Canada; Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Michelle Howard
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amina Jabbar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Trillium Health Partners, Toronto, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- ICES, Toronto, Ontario, Canada; Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Lauren Lapointe-Shaw
- ICES, Toronto, Ontario, Canada; Departments of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada.
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30
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Williamson LE, Evans CJ, Cripps RL, Leniz J, Yorganci E, Sleeman KE. Factors Associated With Emergency Department Visits by People With Dementia Near the End of Life: A Systematic Review. J Am Med Dir Assoc 2021; 22:2046-2055.e35. [PMID: 34273269 DOI: 10.1016/j.jamda.2021.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/10/2021] [Accepted: 06/04/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Emergency department (ED) attendance is common among people with dementia and increases toward the end of life. The aim was to systematically review factors associated with ED attendance among people with dementia approaching the end of life. DESIGN Systematic search of 6 databases (MEDLINE, EMBASE, ASSIA, CINAHL, PsycINFO, and Web of Science) and gray literature. Quantitative studies of any design were eligible. Newcastle-Ottawa Scales and Cochrane risk-of-bias tools assessed study quality. Extracted data were reported narratively, using a theoretical model. Factors were synthesized based on strength of evidence using vote counting (PROSPERO registration: CRD42020193271). SETTING AND PARTICIPANTS Adults with dementia of any subtype and severity, in the last year of life, or in receipt of services indicative of nearness to end of life. MEASUREMENTS The primary outcome was ED attendance, defined as attending a medical facility that provides 24-hour access to emergency care, with full resuscitation resources. RESULTS After de-duplication, 18,204 titles and abstracts were screened, 367 were selected for full-text review and 23 studies were included. There was high-strength evidence that ethnic minority groups, increasing number of comorbidities, neuropsychiatric symptoms, previous hospital transfers, and rural living were positively associated with ED attendance, whereas higher socioeconomic position, being unmarried, and living in a care home were negatively associated with ED attendance. There was moderate-strength evidence that being a woman and receiving palliative care were negatively associated with ED attendance. There was only low-strength evidence for factors associated with repeat ED attendance. CONCLUSIONS AND IMPLICATIONS The review highlights characteristics that could help identify patients at risk of ED attendance near the end of life and potential service-related factors to reduce risks. Better understanding of the mechanisms by which residential facilities and palliative care are associated with reduced ED attendance is needed.
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Affiliation(s)
- Lesley E Williamson
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom.
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom; Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, United Kingdom
| | - Rachel L Cripps
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Javiera Leniz
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Emel Yorganci
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
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Eyles E, Redaniel MT, Purdy S, Tilling K, Ben-Shlomo Y. Associations of GP practice characteristics with the rate of ambulatory care sensitive conditions in people living with dementia in England: an ecological analysis of routine data. BMC Health Serv Res 2021; 21:613. [PMID: 34182996 PMCID: PMC8240405 DOI: 10.1186/s12913-021-06634-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hospital admissions for Ambulatory Care Sensitive Conditions (ACSCs) are potentially avoidable. Dementia is one of the leading chronic conditions in terms of variability in ACSC admissions by general practice, as well as accounting for around a third of UK emergency admissions. METHODS Using Bayesian multilevel linear regression models, we examined the ecological association of organizational characteristics of general practices (ACSC n=7076, non-ACSC n=7046 units) and Clinical Commissioning Groups (CCG n=212 units) in relation to ACSC and non-ACSC admissions for people with dementia in England. RESULTS The rate of hospital admissions are variable between GP practices, with deprivation and being admitted from home as risk factors for admission for ACSC and non-ACSC admissions. The budget allocated by the CCG to mental health shows diverging effects for ACSC versus non-ACSC admissions, so it is likely there is some geographic variation. CONCLUSIONS A variety of factors that could explain avoidable admissions for PWD at the practice level were examined; most were equally predictive for avoidable and non-avoidable admissions. However, a high amount of variation found at the practice level, in conjunction with the diverging effects of the CCG mental health budget, implies that guidance may be applied inconsistently, or local services may have differences in referral criteria. This indicates there is potential scope for improvement.
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Affiliation(s)
- Emily Eyles
- The National Institute for Health Research and Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK. .,Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 58 Whiteladies Rd, Bristol, BS8 2PL, UK.
| | - Maria Theresa Redaniel
- The National Institute for Health Research and Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 58 Whiteladies Rd, Bristol, BS8 2PL, UK
| | - Sarah Purdy
- The National Institute for Health Research and Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 58 Whiteladies Rd, Bristol, BS8 2PL, UK
| | - Kate Tilling
- The National Institute for Health Research and Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 58 Whiteladies Rd, Bristol, BS8 2PL, UK
| | - Yoav Ben-Shlomo
- The National Institute for Health Research and Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 58 Whiteladies Rd, Bristol, BS8 2PL, UK
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Healthcare Utilization in Different Stages among Patients with Dementia: A Nationwide Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115705. [PMID: 34073398 PMCID: PMC8199003 DOI: 10.3390/ijerph18115705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/17/2021] [Accepted: 05/24/2021] [Indexed: 11/16/2022]
Abstract
To evaluate the trend of healthcare utilization among patients with dementia (PwD) in different post-diagnosis periods, Taiwan's nationwide population database was used in this study. PwD were identified on the basis of dementia diagnoses during 2002-2011. We further subdivided the cases into 10 groups from the index year to the 10th year after diagnosis. The frequency of emergency department visits and hospitalizations, the length of stay, outpatient and department visits, and the number of medications used were retrieved. The Joinpoint regression approach was used to estimate the annual percent change (APC) of healthcare utilization. The overall trend of healthcare utilization increased with the progression of dementia, with a significant APC during the first to second year after diagnosis (p < 0.01), except that the frequency of outpatient visits showed a decreasing trend with a significant APC from the first to fifth year. All sex- and age-stratified analyses revealed that male gender and old age contributed to greater use of healthcare services but did not change the overall trend. This study provides a better understanding of medical resource utilization across the full spectrum of dementia, which can allow policymakers, physicians, and caregivers to devise better care plans for PwD.
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Abstract
Chronic brain failure, also known as dementia or major neurocognitive disorder, is a syndrome of progressive functional decline characterized by both cognitive and neuropsychiatric symptoms. It can be conceptualized like other organ failure syndromes and its impact on quality of life can be mitigated with proper treatment. Dementia is a risk factor for delirium, and their symptoms can be similar. Patients with dementia can present with agitation that can lead to injury. Logic and reason are rarely successful when attempting to redirect someone with advanced dementia. Interactions that offer a sense of choice are more likely to succeed.
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Harrison JM, Agarwal M, Stone PW, Gracner T, Sorbero M, Dick AW. Does Integration of Palliative Care and Infection Management Reduce Hospital Transfers among Nursing Home Residents? J Palliat Med 2021; 24:1334-1341. [PMID: 33605787 DOI: 10.1089/jpm.2020.0577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: An estimated 50% of nursing home (NH) residents experience hospital transfers in their last year of life, often due to infections. Hospital transfers due to infection are often of little clinical benefit to residents with advanced illness, for whom aggressive treatments are often ineffective and inconsistent with goals of care. Integration of palliative care and infection management (i.e., merging the goals of palliative care and infection management at end of life) may reduce hospital transfers for residents with advanced illness. Objectives: Evaluate the association between integration and (1) all-cause hospital transfers and (2) hospital transfers due to infection. Design: Cross-sectional observational study. Setting/Subjects: 143,223 U.S. NH residents, including 42,761 residents in the advanced stages of dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Measurement: Cross-sectional, nationally representative NH survey data (2017-2018) were combined with resident data from the Minimum Data Set 3.0 and Medicare inpatient data (2016-2017). NH surveys measured integration of palliative care and infection management using an index of 0-100. Logistic regression models were used to estimate the relationships between integration intensity (i.e., the degree to which NHs follow best practices for integration) and all-cause hospital transfer and transfer due to infection. Results: Among residents with advanced dementia, integration intensity was inversely associated with all-cause hospital transfer and transfer due to infection (p < 0.001). Among residents with advanced COPD, integration intensity was inversely associated with all-cause hospital transfer (p < 0.05) but not transfers due to infection. Among residents with advanced CHF, integration intensity was not associated with either outcome. Conclusions: NH policies aimed to promote integration of palliative care and infection management may reduce burdensome hospital transfers for residents with advanced dementia. For residents with advanced CHF and COPD, alternative strategies may be needed to promote best practices for infection management at end of life.
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Affiliation(s)
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, New York, USA
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Brocklehurst P, Hoare Z, Woods C, Williams L, Brand A, Shen J, Breckons M, Ashley J, Jenkins A, Gough L, Preshaw P, Burton C, Shepherd K, Bhattarai N. Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background
Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry.
Objectives
The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis.
Design
A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study.
Setting
The setting was NHS dental practices in North West England.
Participants
A total of 217 low-risk patients in eight high-street dental practices participated.
Interventions
The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm).
Main outcome measure
The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists.
Results
No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined.
Limitations
The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate.
Conclusions
Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value.
Future work
Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation.
Trial registration
Current Controlled Trials ISRCTN70032696.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Zoe Hoare
- School of Health Sciences, Bangor University, Bangor, UK
| | - Chris Woods
- School of Health Sciences, Bangor University, Bangor, UK
| | - Lynne Williams
- School of Health Sciences, Bangor University, Bangor, UK
| | - Andrew Brand
- School of Health Sciences, Bangor University, Bangor, UK
| | - Jing Shen
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Matthew Breckons
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Alison Jenkins
- School of Health Sciences, Bangor University, Bangor, UK
| | | | - Philip Preshaw
- Faculty of Dentistry, National University of Singapore, Singapore
- Faculty of Dentistry, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher Burton
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, UK
| | - Karen Shepherd
- Patient and public involvement representative, Bangor, UK
| | - Nawaraj Bhattarai
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Griffith MF, Levy CR, Parikh TJ, Stevens-Lapsley JE, Eber LB, Palat SIT, Gozalo PL, Teno JM. Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia. J Am Med Dir Assoc 2020; 21:1879-1884. [PMID: 33263287 PMCID: PMC7577734 DOI: 10.1016/j.jamda.2020.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 11/18/2022]
Abstract
Objectives Pneumonia is a common cause of hospitalization for nursing home residents and has increased as a cause for hospitalization during the COVID-19 pandemic. Risks of hospitalization, including significant functional decline, are important considerations when deciding whether to treat a resident in the nursing home or transfer to a hospital. Little is known about postdischarge functional status, relative to baseline, of nursing home residents hospitalized for pneumonia. We sought to determine the risk of severe functional limitation or death for nursing home residents following hospitalization for treatment of pneumonia. Design Retrospective cohort study. Setting and Participants Participants included Medicare enrollees aged ≥65 years, hospitalized from a nursing home in the United States between 2013 and 2014 for pneumonia. Methods Activities of daily living (ADL), patient sociodemographics, and comorbidities were obtained from the Minimum Data Set (MDS), an assessment tool completed for all nursing home residents. MDS assessments from prior to and following hospitalization were compared to assess for functional decline. Following hospital discharge, all patients were evaluated for a composite outcome of severe disability (≥4 ADL limitations) following hospitalization or death prior to completion of a postdischarge MDS. Results In 2013 and 2014, a total of 241,804 nursing home residents were hospitalized for pneumonia, of whom 89.9% (192,736) experienced the composite outcome of severe disability or death following hospitalization for pneumonia. Although we found that prehospitalization functional and cognitive status were associated with developing the composite outcome, 53% of residents with no prehospitalization ADL limitation, and 82% with no cognitive limitation experienced the outcome. Conclusions and Implications Hospitalization for treatment of pneumonia is associated with significant risk of functional decline and death among nursing home residents, even those with minimal deficits prior to hospitalization. Nursing homes need to prepare for these outcomes in both advance care planning and in rehabilitation efforts.
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Affiliation(s)
- Matthew F Griffith
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA.
| | - Cari R Levy
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - Toral J Parikh
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Jennifer E Stevens-Lapsley
- Geriatric Research Education and Clinical Center (GRECC), VA Eastern Colorado Health Care System, Aurora, CO, USA
| | | | - Sing-I T Palat
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI, USA
| | - Joan M Teno
- Division of General Internal Medicine, Oregon Health and Science University, Portland, OR, USA
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Manu ER, Fitzgerald JT, Mullan PB, Vitale CA. Eating Problems in Advanced Dementia: Navigating Difficult Conversations. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:11025. [PMID: 33241119 PMCID: PMC7678029 DOI: 10.15766/mep_2374-8265.11025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 07/02/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION The majority of older adults with advanced dementia (AD) develop difficulties with eating and swallowing, often prompting concerns about nutrition and quality of life. Employing a palliative approach requires providers to attain skills in addressing symptoms and communicating with family caregivers about the trajectory of AD and associated dysphagia, as well as to elicit goals of care. Research suggests internal medicine (IM) residents often perceive minimal education during training addressing skills needed to care for patients with AD. METHODS We developed and piloted a small-group interactive seminar utilizing a trigger video depicting a family meeting addressing eating problems in a patient with AD. Case-based learning, small-group discussion, and learner reflection were employed. We assessed the impact on 82 of the 106 IM, medicine-pediatrics, and neurology residents who participated in the seminar. RESULTS Participant evaluation indicated residents showed high satisfaction and perceived the educational content of the seminar to be robust and clinically relevant. We found statistically significant (p < .001) improvements in self-reported confidence in dementia-specific skills postseminar. Effect size was large to very large (Cohen's d = 1.3-1.7). DISCUSSION An interactive, case-based seminar utilizing a video depicting a realistic family meeting improved residents' self-efficacy in skills needed to address nutritional issues, engage in goals-of-care discussions, and reflect on concerns among caregivers of patients with AD. The seminar teaches important geriatric and palliative concepts meant to improve residents' ability to care for older adults with AD in their future careers.
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Affiliation(s)
- Erika R. Manu
- Assistant Professor, Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School; Physician, VA Ann Arbor Geriatric Research, Education and Clinical Center (GRECC)
| | - James T. Fitzgerald
- Professor Emeritus, Department of Learning Health Sciences, University of Michigan Medical School
| | - Patricia B. Mullan
- Professor Emerita, Department of Learning Health Sciences, University of Michigan Medical School
| | - Caroline A. Vitale
- Professor, Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School; Associate Director of Education and Evaluation, VA Ann Arbor Geriatric Research, Education and Clinical Center (GRECC)
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Lundberg A, Hillebrecht AL, McKenna G, Srinivasan M. COVID-19: Impacts on oral healthcare delivery in dependent older adults. Gerodontology 2020; 38:174-178. [PMID: 33169864 DOI: 10.1111/ger.12509] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/28/2020] [Accepted: 10/26/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the impacts of restrictions to the provision of dental services for dependent older patients due to the COVID-19 pandemic. METHODS Data were gathered on the number of dependent older patients treated, emergency treatment provided and the revenues generated by a specialised clinic for geriatric dentistry during the current pandemic period and compared with the recorded clinical activity from the preceding year. Hypothetical projections were generated for the remainder of the current year based on the assumption that restrictions due to COVID-19 would remain. RESULTS A significant decrease in the total number of dependent older patients treated was recorded during the periods of January-March 2020 (P = .026) and April-May 2020 (P = .001) when compared to 2019. According to projections, by December 2020 the clinic will be providing 81.14% less clinical activity compared to 2019 (P < .0001), including a complete cessation of domiciliary services. Despite decreases in expenditure, revenues generated by the clinic have decreased significantly due to reduced clinical activity during January-March 2020 (P = .268) and April-May 2020 (P = .010) compared to 2019, and would decline further by 899.61% by December 2020. CONCLUSIONS The restrictions implemented to prevent the spread of COVID-19 have resulted in a significant reduction in oral healthcare provision for dependent older adults. Within this clinic, dedicated to dependent older adults, clinical activity is projected to reduce by 81% by the end of 2020 with associated reductions in revenue generation. Given the importance of oral healthcare delivery for this patient group, this may have significant and lasting impacts.
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Affiliation(s)
- Andrea Lundberg
- Clinic of General, Special Care, and Geriatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Anna-Lena Hillebrecht
- Clinic of General, Special Care, and Geriatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Gerald McKenna
- School of Medicine, Dentistry and Biomedical Sciences, Center for Public Health, Queen's University Belfast, Belfast, UK
| | - Murali Srinivasan
- Clinic of General, Special Care, and Geriatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
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Ghneim M, Diaz JJ. Dementia and the Critically Ill Older Adult. Crit Care Clin 2020; 37:191-203. [PMID: 33190770 DOI: 10.1016/j.ccc.2020.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Dementia is a terminal illness that leads to progressive cognitive and functional decline. As the elderly population grows, the incidence of dementia in hospitalized older adults increases and is associated with poor short-term and long-term outcomes. Delirium is associated with an accelerated cognitive decline in hospitalized patients with dementia. The first step in the management of dementia is accurate and early diagnosis. Evidence-based management guidelines in the setting of critical illness and dementia are lacking. The cornerstone of management is defining goals of care early in the course of hospitalization and using palliative care and hospice when deemed appropriate.
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Affiliation(s)
- Mira Ghneim
- R Adams Cowley Shock Trauma Center, The University of Maryland Medical Center, 22 South Green Street, S4D07, Baltimore, MD 21201, USA.
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, The University of Maryland Medical Center, 22 South Green Street, S4D07, Baltimore, MD 21201, USA
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Courtright KR, Srinivasan TL, Madden VL, Karlawish J, Szymanski S, Hill SH, Halpern SD, Ersek M. "I Don't Have Time to Sit and Talk with Them": Hospitalists' Perspectives on Palliative Care Consultation for Patients with Dementia. J Am Geriatr Soc 2020; 68:2365-2372. [PMID: 32748393 PMCID: PMC8485634 DOI: 10.1111/jgs.16712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 06/20/2020] [Accepted: 06/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Specialty palliative care for hospitalized patients with dementia is widely recommended and may improve outcomes, yet rates of consultation remain low. We sought to describe hospitalists' decision-making regarding palliative care consultation for patients with dementia. DESIGN Descriptive qualitative study. SETTING Seven hospitals within a national nonprofit health system. PARTICIPANTS Hospitalist physicians. MEASUREMENTS Individual semistructured interviews. We used thematic analysis to explore factors that influence hospitalists' decision to consult palliative care for patients with dementia. RESULTS A total of 171 hospitalists were eligible to participate, and 28 (16%) were interviewed; 17 (61%) were male, 16 (57%) were white, and 18 (64%) were in practice less than 10 years. Overall, hospitalists' decisions to consult palliative care for patients with dementia were influenced by multiple factors across four themes: patient, family caregiver, hospitalist, and organization. Consultation was typically only considered for patients with advanced disease, particularly those receiving aggressive care or with family communication needs (navigating conflicts around goals of care and improving disease and prognostic understanding). Hospitalists' limited time and, for some, a lack of confidence in palliative care skills were strong drivers of consultation. Palliative care needs notwithstanding, most hospitalists would not request consultation if they perceived families would be resistant to it or had limited availability or involvement in caregiving. Additional barriers to referral at the organization level included a hospital culture that conflated palliative and end-of-life care and busy palliative care teams at some hospitals. CONCLUSION Hospitalists described a complex consultation decision process for involving palliative care specialists in the care of patients with dementia. Systematic identification of hospitalized patients with dementia most likely to benefit from palliative care consultation and strategies to overcome modifiable family and organization barriers are needed. J Am Geriatr Soc 68:2365-2372, 2020.
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Affiliation(s)
- Katherine R. Courtright
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Roybal Center on Palliative Care in Dementia, Philadelphia, Pennsylvania
| | - Trishya L. Srinivasan
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vanessa L. Madden
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason Karlawish
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Roybal Center on Palliative Care in Dementia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania
- Institute on Aging, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Memory Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephanie Szymanski
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Scott D. Halpern
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Roybal Center on Palliative Care in Dementia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Ersek
- Penn Roybal Center on Palliative Care in Dementia, Philadelphia, Pennsylvania
- Institute on Aging, University of Pennsylvania, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Veteran Affairs, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Dooley J, Booker M, Barnes R, Xanthopoulou P. Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences. BMJ Open 2020; 10:e037673. [PMID: 32938596 PMCID: PMC7497532 DOI: 10.1136/bmjopen-2020-037673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/22/2020] [Accepted: 07/08/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES People with dementia are more vulnerable to complications in urgent health situations due to older age, increased comorbidity, higher dependency on others and cognitive impairment. This review explored the factors associated with urgent care use in dementia and the experiences of people with dementia, informal carers and professionals. DESIGN Scoping review. The search strategy and data synthesis were informed by people with dementia and carers. DATA SOURCES Searches of CINAHL, Embase, Medline, PsycINFO, PubMed were conducted alongside handsearches of relevant journals and the grey literature through 15 January 2019. ELIGIBILITY CRITERIA Empirical studies including all research designs, and other published literature exploring factors associated with urgent care use in prehospital and emergency room settings for people with dementia were included. Two authors independently screened studies for inclusion. DATA EXTRACTION AND SYNTHESIS Data were extracted using charting techniques and findings were synthesised according to content and themes. RESULTS Of 2967 records identified, 54 studies were included in the review. Specific factors that influenced use of urgent care included: (1) common age-related conditions occurring alongside dementia, (2) dementia as a diagnosis increasing or decreasing urgent care use, (3) informal and professional carers, (4) patient characteristics such as older age or behavioural symptoms and (5) the presence or absence of community support services. Included studies reported three crucial components of urgent care situations: (1) knowledge of the patient and dementia as a condition, (2) inadequate non-emergency health and social care support and (3) informal carer education and stress. CONCLUSIONS The scoping review highlighted a wider variety of sometimes competing factors that were associated with urgent care situations. Improved and increased community support for non-urgent situations, such as integrated care, caregiver education and dementia specialists, will both mitigate avoidable urgent care use and improve the experience of those in crisis.
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Affiliation(s)
- Jemima Dooley
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Matthew Booker
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Rebecca Barnes
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
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Sutherland N. Structures, tensions, and processes shaping long-term care home staff's role in end of life decision-making for residents with dementia. J Aging Stud 2020; 54:100874. [PMID: 32972618 DOI: 10.1016/j.jaging.2020.100874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 08/23/2020] [Accepted: 08/26/2020] [Indexed: 12/27/2022]
Abstract
Although long-term care (LTC) home staff of nurses and personal support workers spend the most time providing direct care, their role in end of life decision-making for residents with dementia has largely been unacknowledged. Staff's perceptions of their role play a significant part in how they support people with dementia and family care partners. The purpose of this study was to examine LTC home staff's perspectives of their role in end of life decision-making for LTC home residents with dementia. For this interpretive descriptive study, 21 semi-structured interviews were conducted in two urban LTC homes with nine personal support worker (PSWs), eight registered practical nurses (RPNs), and four registered nurses (RNs). Additionally, a focus group was conducted, consisting of each a PSW, RPN, and RN. A voice-centred relational analysis was used to situate LTC home staff's perspectives within broader social contexts. Findings suggest that little has changed in LTC homes in the last 50 years. Rooted in dichotomies between medical and social care paradigms, ideologies of rationality and professionalism created tensions, hierarchical roles, and staff's minimal involvement in decision-making. A relational approach is needed to account for the interdependency of care and the relationships that LTC home staff have with residents, family care partners, and the sociopolitical environment.
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Affiliation(s)
- Nisha Sutherland
- Lakehead University, 955 Oliver Road, Thunder Bay, ON P7B 5E1, Canada.
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Martinsson L, Lundström S, Sundelöf J. Better quality of end-of-life care for persons with advanced dementia in nursing homes compared to hospitals: a Swedish national register study. BMC Palliat Care 2020; 19:135. [PMID: 32847571 PMCID: PMC7449048 DOI: 10.1186/s12904-020-00639-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/13/2020] [Indexed: 11/25/2022] Open
Abstract
Background Hospitalisation of patients with advanced dementia is generally regarded as less preferable compared to care at home or in a nursing home. For patients with other diagnoses, young age has been associated with better end-of-life care. However, studies comparing the quality of palliative care for persons with advanced dementia in hospitals and nursing homes are scarce. The aim of this study was to investigate whether quality of end-of-life care for patients with dementia depends on age, gender and place of death. Methods The Swedish Register of Palliative Care (SRPC) was used to identify patients who died from dementia in hospitals or nursing homes during a three-year period. The likelihood of death occurring at a hospital, based on age and gender differences, was calculated. Associations between 13 end-of-life care quality indicators collected from the SRPC and age, gender and place of care were examined in a logistic regression model. Results Death at a hospital was associated with poorer quality of end-of-life care for 10 of the 13 measured outcomes when compared to death at a nursing home, and with better quality according to two of the outcomes. Death at a hospital was more common for men compared to women and for younger patients compared to older. Receiving fluids intravenously or via enteral tube in the last 24 h of life was strongly associated with death at a hospital. Women were more likely to have their oral health assessed and less likely to have pressure ulcers at death. Eight of 12 end-of-life care outcomes showed better results for the age group 65 to 84 years compared to those 85 years or older. Conclusions Death in hospitals was associated with poorer quality of end-of-life care compared to death in nursing homes. Our data support the importance of advance care planning and individual assessments in nursing homes to avoid referral to hospitals during end of life. Despite established recommendations to avoid hospitalisation if possible, there were strong associations between younger age, male gender and hospitalisation in the end of life. Further studies are needed to investigate the role of socioeconomic factors in end-of-life care for this patient group.
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Affiliation(s)
- Lisa Martinsson
- Department of Radiation Sciences, Umeå University, SE 907 87, Umeå, Sweden.
| | - Staffan Lundström
- Department of Palliative Medicine, Stockholms Sjukhem Foundation, SE 112 19, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, SE 171 77, Stockholm, Sweden
| | - Johan Sundelöf
- Betaniastiftelsen (non-profit organisation), SE 116 20, Stockholm, Sweden
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Anderson TS, Marcantonio ER, McCarthy EP, Herzig SJ. National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia. J Am Geriatr Soc 2020; 68:2240-2248. [PMID: 32700399 DOI: 10.1111/jgs.16636] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/09/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND/OBJECTIVES Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking. DESIGN Retrospective cohort study using the National Inpatient Sample from 2012 to 2016. SETTING U.S. acute care hospitals. PARTICIPANTS A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia. MEASUREMENTS Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs. RESULTS The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community. CONCLUSION The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020.
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Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ellen P McCarthy
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Shoshana J Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Miranda R, van der Steen JT, Smets T, Van den Noortgate N, Deliens L, Payne S, Kylänen M, Szczerbińska K, Gambassi G, Van den Block L. Comfort and clinical events at the end of life of nursing home residents with and without dementia: The six-country epidemiological PACE study. Int J Geriatr Psychiatry 2020; 35:719-727. [PMID: 32128874 DOI: 10.1002/gps.5290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES We aimed to investigate the occurrence rates of clinical events and their associations with comfort in dying nursing home residents with and without dementia. METHODS Epidemiological after-death survey was performed in nationwide representative samples of 322 nursing homes in Belgium, Finland, Italy, the Netherlands, Poland, and England. Nursing staff reported clinical events and assessed comfort. The nursing staff or physician assessed the presence of dementia; severity was determined using two highly discriminatory staff-reported instruments. RESULTS The sample comprised 401 residents with advanced dementia, 377 with other stages of dementia, and 419 without dementia (N = 1197). Across the three groups, pneumonia occurred in 24 to 27% of residents. Febrile episodes (unrelated to pneumonia) occurred in 39% of residents with advanced dementia, 34% in residents with other stages of dementia and 28% in residents without dementia (P = .03). Intake problems occurred in 74% of residents with advanced dementia, 55% in residents with other stages of dementia, and 48% in residents without dementia (P < .001). Overall, these three clinical events were inversely associated with comfort. Less comfort was observed in all resident groups who had pneumonia (advanced dementia, P = .04; other stages of dementia, P = .04; without dementia, P < .001). Among residents with intake problems, less comfort was observed only in those with other stages of dementia (P < .001) and without dementia (P = .003), while the presence and severity of dementia moderated this association (P = .03). Developing "other clinical events" was not associated with comfort. CONCLUSIONS Discomfort was observed in dying residents who developed major clinical events, especially pneumonia, which was not specific to advanced dementia. It is crucial to identify and address the clinical events potentially associated with discomfort in dying residents with and without dementia.
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Affiliation(s)
- Rose Miranda
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, Expertise center for Palliative Care, Amsterdam, The Netherlands.,Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University Hospital, Ghent, Belgium
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Marika Kylänen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Katarzyna Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Giovanni Gambassi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Fassmer AM, Hoffmann F. Acute health care services use among nursing home residents in Germany: a comparative analysis of out-of-hours medical care, emergency department visits and acute hospital admissions. Aging Clin Exp Res 2020; 32:1359-1368. [PMID: 31428997 DOI: 10.1007/s40520-019-01306-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 08/05/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Nursing home (NH) residents often utilise acute health care services. However, comparative data on those are lacking. AIMS Investigating German NH residents' use of out-of-hours medical care (OOHC), visits to emergency departments (EDs) and acute hospital admissions (AHAs). METHODS Using claims data of 1665 residents for 2014-2015, we conducted a retrospective cohort study, examining the incidence rates involving the different services. Multivariate Poisson regression analyses were performed to calculate relative risks (RRs). Differences in the utilisations over the days of the week and of the reasons for contacts were assessed. RESULTS In total, 3576 contacts occurred (mean age 80.5 years, women 66.3%), resulting in an overall incidence rate of 2.7 per person-year (95% confidence interval 2.6-2.8). Strongest predictors were polypharmacy (RR 1.79; 95% CI 1.50-2.12), followed by male sex and higher care dependency. Among the three services AHAs showed the highest rates. Injuries were the most common reasons for visiting EDs, whereas for OOHC use and AHAs, coded diagnoses covered a broader spectrum. Utilisation of the services on weekdays varied, particularly for OOHC. DISCUSSION Polypharmacy, a higher care dependency and male sex seem to play a role in predicting acute health care services. Considering the distribution of the diagnoses of all three types, certain patterns concerning the symptoms' acuity become apparent. CONCLUSIONS Our findings revealed high acute health care services use among NH residents in Germany and differences among the three available services. This information can be used to design studies for investigating the appropriateness of these contacts.
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Affiliation(s)
- Alexander Maximilian Fassmer
- Department of Health Services Research, VI. School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstr. 114-118, 26129, Oldenburg, Germany.
| | - Falk Hoffmann
- Department of Health Services Research, VI. School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstr. 114-118, 26129, Oldenburg, Germany
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47
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Alcorn G, Murray SA, Hockley J. Care home residents who die in hospital: exploring factors, processes and experiences. Age Ageing 2020; 49:468-480. [PMID: 32091569 DOI: 10.1093/ageing/afz174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 11/11/2019] [Accepted: 12/04/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Care home residents are increasingly frail with complex health and social care needs. Their transfer to hospital at the end-of-life can be associated with unwanted interventions and distress. However, hospitals do enable provision of care that some residents wish to receive. We aimed to explore the factors that influence hospital admission of care home residents who then died in hospital. METHODS This study combined in-depth case note review of care home residents dying in two Scottish teaching hospitals during a 6-month period and semi-structured interviews with a purposive sample of 26 care home staff and two relatives. RESULTS During the 6-month period, 109 care home residents died in hospital. Most admissions occurred out-of-hours (69%) and most were due to a sudden event or acute change in clinical condition (72%). Length of stay in hospital before death was short, with 42% of deaths occurring within 3 days. Anticipatory Care Planning (ACP) regarding hospital admission was documented in 44%.Care home staff wanted to care for residents who were dying; however, uncertain trajectories of decline, acute events, challenges of ACP, relationship with family and lack of external support impeded this. CONCLUSIONS Managing acute changes on the background of uncertain trajectories is challenging in care homes. Enhanced support is required to improve and embed ACP in care homes and to provide rapid, 24 hours-a-day support to manage difficult symptoms and acute changes.
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Affiliation(s)
- Gemma Alcorn
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh
| | - Scott A Murray
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh
| | - Jo Hockley
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh
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McCarthy EP, Ogarek JA, Loomer L, Gozalo PL, Mor V, Hamel MB, Mitchell SL. Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations. JAMA Intern Med 2020; 180:385-394. [PMID: 31886827 PMCID: PMC6990757 DOI: 10.1001/jamainternmed.2019.6130] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population. OBJECTIVE To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017-before and after the introduction of national initiatives to reduce hospitalizations. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019. MAIN OUTCOMES AND MEASURES The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained. RESULTS The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%). CONCLUSIONS AND RELEVANCE The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.
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Affiliation(s)
- Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Mary Beth Hamel
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Zinsaz H, Calder G, Corallo C, Gibson PR, Poojary S, Moran C. Initial experiences of an in-reach service providing iron infusions in residential aged care facilities. Australas J Ageing 2020; 39:e454-e459. [PMID: 32090443 DOI: 10.1111/ajag.12776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/14/2020] [Accepted: 01/18/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the feasibility of developing an in-reach parenteral iron infusion service to residents of residential aged care facilities (RACFs). METHODS An audit comparing the use of iron infusions in RACFs prior to and following the introduction of an in-reach iron infusion service. RESULTS Of the 738 inpatient iron infusions administered to inpatients ≥65 years in the 12 months prior to the in-reach service, 52 (7%) lived in an RACF, with no significant adverse events reported. After implementation of an in-reach service, a total of 37 RACF residents received parenteral iron in the first 12 months of the service, with no significant adverse events reported. CONCLUSION It is possible to safely provide parenteral iron through an in-reach service to residents in RACF. Further research is required to identify the person-level benefits achieved by this service.
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Affiliation(s)
- Hamed Zinsaz
- Department of Aged Care, Alfred Health, Melbourne, Vic., Australia.,Department of Aged Care, Monash Health, Melbourne, Vic., Australia
| | - Georgina Calder
- Mobile Assessment and Treatment Service, Alfred Health, Melbourne, Vic., Australia
| | - Carmela Corallo
- Pharmacy Department, Alfred Health, Melbourne, Vic., Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Vic., Australia
| | - Suma Poojary
- Department of Aged Care, Alfred Health, Melbourne, Vic., Australia.,Mobile Assessment and Treatment Service, Alfred Health, Melbourne, Vic., Australia
| | - Chris Moran
- Department of Aged Care, Alfred Health, Melbourne, Vic., Australia.,Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Vic., Australia.,Department of Aged Care, Peninsula Health, Melbourne, Vic., Australia
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Eisenmann Y, Golla H, Schmidt H, Voltz R, Perrar KM. Palliative Care in Advanced Dementia. Front Psychiatry 2020; 11:699. [PMID: 32792997 PMCID: PMC7394698 DOI: 10.3389/fpsyt.2020.00699] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/02/2020] [Indexed: 12/20/2022] Open
Abstract
Dementia syndrome is common and expected to increase significantly among older people and characterized by the loss of cognitive, psychological and physical functions. Palliative care is applicable for people with dementia, however they are less likely to have access to palliative care. This narrative review summarizes specifics of palliative care in advanced dementia. Most people with advanced dementia live and die in institutional care and they suffer a range of burdensome symptoms and complications. Shortly before dying people with advanced dementia suffer symptoms as pain, eating problems, breathlessness, neuropsychiatric symptoms, and complications as respiratory or urinary infections and frequently experience burdensome transitions. Pharmacological and nonpharmacological interventions may reduce symptom burden. Sensitive observation and appropriate assessment tools enable health professionals to assess symptoms and needs and to evaluate interventions. Due to lack of decisional capacity, proxy decision making is often necessary. Advanced care planning is an opportunity establishing values and preferences and is associated with comfort and decrease of burdensome interventions. Family carers are important for people with advanced dementia they also experience distress and are in need for support. Recommendations refer to early integration of palliative care, recognizing signs of approaching death, symptom assessment and management, advanced care planning, person-centered care, continuity of care, and collaboration of health care providers.
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Affiliation(s)
- Yvonne Eisenmann
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Holger Schmidt
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Clinical Trials Center (ZKS), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Health Services Research, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Klaus Maria Perrar
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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