Development and Pilot Analysis of the Nursing Home Health Information Technology Maturity Survey and Staging Model

The current research includes a psychometric test of a nursing home (NH) health information technology (HIT) maturity survey and staging model. NHs were assembled based on HIT survey scores from a prior study representing NHs with low (20%), medium (60%), and high (20%) HIT scores. Inclusion criteria were NHs that completed at least two annual surveys over 4 years. NH administrators were excluded who participated in the Delphi panel responsible for instrument recommendations. Recruitment occurred from January to May 2019. Administrators from 121 of 429 facilities completed surveys. NHs were characteristically for-profit, medium bed size, and metropolitan. A covariance matrix demonstrated that all dimensions and domains were significantly correlated, except HIT capabilities and integration in administrative activities. Cronbach's alpha was very good (0.86). Principal component analysis revealed all items loaded intuitively onto four components, explaining 80% variance. The HIT maturity survey and staging model can be used to assess nine dimensions and domains, total HIT maturity, and stage, leading to reliable assumptions about NH HIT. [Research in Gerontological Nursing, 15(2), 93-99.].

Protocol for targeting insomnia in school-aged children with autism spectrum disorder without intellectual disability: a randomised control trial

INTRODUCTION

Insomnia affects up to 80% of children with autism spectrum disorder (ASD). Negative consequences of insomnia in ASD include decreased quality of life (QOL), impaired learning and cognition, increased stereotypic and challenging behaviours, and increased parental stress. Cognitive behavioural treatment for childhood insomnia (CBT-CI) is a promising treatment for dealing with insomnia and its negative consequences but has not yet been studied in school-aged children with ASD and comorbid insomnia. Access to healthcare is another challenge for children with ASD, particularly in rural and underserved regions. Previous studies indicate that ASD and insomnia share common arousal-based underpinnings, and we hypothesise that CBT-CI will reduce the hyperarousal associated with insomnia and ASD. This trial will be the first to examine CBT-CI adapted for children with ASD and will provide new information about two different modes of delivery across a variety of primary and secondary child and parent sleep and related outcomes. Knowledge obtained from this trial might allow us to develop new or modify current treatments to better target childhood insomnia and ASD.

METHODS AND ANALYSIS

Children (N=180) 6-12 years of age with ASD and insomnia will be recruited from an established autism database, a paediatric clinic and community outreach in the Columbia, MO and surrounding areas. Participants will be randomised to CBT-CI adapted for children with ASD (in-person or remote using computers with cameras) or Sleep Hygiene and Related Education. Participants will be assessed at baseline, post-treatment, 6-month and 12-month follow-ups. The following assessments will be completed regarding the children: objective and subjective sleep, daytime functioning (adaptive functioning, attention, challenging behaviours, anxiety), QOL and physiological arousal (heart rate variability) and parents: objective and subjective sleep, daytime functioning (anxiety, depression, fatigue), QOL, physiological arousal and parental burden/stress.

ETHICS AND DISSEMINATION

Ethics approval was obtained in January 2020 from the University of Missouri. Ethics approval was obtained in July 2020 from the US Army Medical Research and Development Command, Office of Research Protections and Human Research Protection Office. All data are expected to be collected by 2024. Full trial results are planned to be published by 2025. Secondary analyses of baseline data will be subsequently published.

TRIAL REGISTRATION NUMBER

NCT04545606; Pre-results.

Sleep and alcohol use among young adult drinkers with Insomnia: A daily process model

BACKGROUND

Previous studies examining associations between sleep and alcohol use have done so primarily at the aggregate (between-person) level and primarily among healthy young adults. This study aimed to examine reciprocal, within-person associations between sleep and alcohol use among young adult drinkers with insomnia.

METHODS

Young adults who engaged in past-month binge drinking and met diagnostic criteria for insomnia (N = 56) wore wrist actigraphy and completed online daily diaries assessing sleep and drinking for an average of 8.52 days (SD = 2.31), resulting in 477 reports. Multilevel models were used to examine within- and between-person effects of sleep quality and efficiency on alcohol use and vice versa. Bedtime and waketime were included as secondary sleep parameters.

RESULTS

Participants reported drinking on 231 days (48%). Participants did not report significantly different sleep quality on heavier-drinking days, nor did they demonstrate significant changes in actigraphy-measured sleep efficiency. However, they self-reported better sleep efficiency on heavier-drinking days (driven primarily by improvements in sleep onset latency), and they reported heavier drinking following days of better sleep efficiency (driven by improvements in total sleep time). Drinking was also associated with later bedtimes and waketimes.

CONCLUSIONS

Young adult drinkers with insomnia report reciprocal associations between subjective sleep efficiency and alcohol use, but these results were not replicated using objective measures. Providers may need to challenge the belief that there is a positive association between alcohol use and sleep among young adults who drink and have insomnia.

Usability Evaluation of a Smartphone Medication Reminder Application in Patients Treated With Short-term Antibiotic

Medication adherence is poor in persons with chronic disease, especially in those with multiple chronic diseases, one of which is a psychological disorder. Social support, medication education, and external reminders have been identified as facilitators of adherence. Mobile health applications have the potential to enhance adherence; however, it is unknown if publicly available applications are user-friendly and useful. We aimed to examine the usability and feasibility of the "MediSafe" medication reminder application in adults with diarrhea-predominant irritable bowel syndrome undergoing short-term antibiotic therapy and a "Medfriend" from their social support network (N = 14). A mixed-methods study was conducted. All patient participants used the MediSafe application daily for 14 days. Ease of use, ease of learning, and satisfaction scales were rated highest by both patient participants and Medfriends, whereas usefulness was rated lowest by both groups, with Medfriends' usefulness rating significantly lower than that of patient participants. Telephone interviews identified patient participants found the application instrumental in facilitating medication adherence, and Medfriends viewed themselves as active participants in the patient participants' care. The MediSafe medication reminder application is easy to use and accepted by both patients and their designated Medfriend. The MediSafe is instrumental in facilitating short-term antibiotic adherence and social support engagement.

Cognitive behavioral therapy for insomnia among young adults who are actively drinking: a randomized pilot trial

STUDY OBJECTIVES

More than half of young adults at risk for alcohol-related harm report symptoms of insomnia. Insomnia symptoms, in turn, have been associated with alcohol-related problems. Yet one of the first-line treatments for insomnia (Cognitive Behavioral Therapy for Insomnia or CBT-I) has not been tested among individuals who are actively drinking. This study tested (1) the feasibility and short-term efficacy of CBT-I among binge-drinking young adults with insomnia and (2) improvement in insomnia as a predictor of improvement in alcohol use outcomes.

METHODS

Young adults (ages 18-30 years, 75% female, 73% college students) who met criteria for Insomnia Disorder and reported 1+ binge drinking episode (4/5+ drinks for women/men) in the past month were randomly assigned to 5 weekly sessions of CBT-I (n = 28) or single-session sleep hygiene (SH, n = 28). All participants wore wrist actigraphy and completed daily sleep surveys for 7+ days at baseline, posttreatment, and 1-month follow-up.

RESULTS

Of those randomized, 43 (77%) completed posttreatment (19 CBT-I, 24 SH) and 48 (86%) completed 1-month follow-up (23 CBT-I, 25 SH). CBT-I participants reported greater posttreatment decreases in insomnia severity than those in SH (56% vs. 32% reduction in symptoms). CBT-I did not have a direct effect on alcohol use outcomes; however, mediation models indicated that CBT-I influenced change in alcohol-related consequences indirectly through its influence on posttreatment insomnia severity.

CONCLUSIONS

CBT-I is a viable intervention among individuals who are actively drinking. Research examining improvement in insomnia as a mechanism for improvement in alcohol-related consequences is warranted.

TRIAL REGISTRATION

U.S. National Library of Medicine, https://clinicaltrials.gov/ct2/show/NCT03627832, registration #NCT03627832.

Using Sensor Signals in the Early Detection of Heart Failure: A Case Study

Early detection of heart failure in older adults will be a significant issue for the foreseeable future. The current article presents a case study to describe how monitoring ballistocardiogram (BCG) waveforms captured non-invasively using sensors placed under a bed mattress can detect early heart failure changes. Heart and respiratory rates obtained from the bed sensor of a female older adult who was hospitalized with acute mixed congestive heart failure, clinic notes, and data from computer simulations reflecting increasing diastolic dysfunction were analyzed. Mean heart and respiratory rate trends obtained from her bed sensor in the prior 2 months did not indicate heart failure. BCG waveforms resulting from the simulations demonstrated changes associated with decreasing cardiac output as diastolic function worsened. Developing new methods for clinically interpreting BCG waveforms presents a significant opportunity for improving early heart failure detection. [Journal of Gerontological Nursing, 46(7), 41-46.].

Daily associations between sleep and opioid use among adults with comorbid symptoms of insomnia and fibromyalgia

STUDY OBJECTIVES

Disturbed sleep and use of opioid pain medication are common among individuals with chronic pain. Anecdotally, opioids are thought to promote sleep by relieving pain. This study aimed to determine whether opioid use is associated with daily sleep parameters (and vice versa) in adults with comorbid symptoms of insomnia and fibromyalgia.

METHODS

Individuals reporting symptoms of insomnia and opioid use for fibromyalgia (n = 65, 93% women, 79% White) wore wrist actigraphy and completed daily diaries for 14 days (910 observations). Analyses examined daily associations between opioid dose (measured in lowest recommended dosage units) and three sleep parameters (actigraphy/self-reported total wake time and self-reported sleep quality). Multilevel models were used to account for the clustering of daily sleep and opioid assessments (level 1) within individuals (level 2).

RESULTS

Opioid use did not have a significant daily effect on total wake time or sleep quality, and sleep parameters did not significantly impact opioid use the next day; however, participants reported worse sleep quality and greater doses of opioids on evenings that they experienced greater pain.

CONCLUSIONS

Among adults reporting symptoms of insomnia and opioid use for fibromyalgia pain, opioid use is not reliably associated with wake time or sleep quality that night, and these sleep parameters are not significantly associated with opioid use the next day; however, evening pain has an adverse daily impact on both sleep quality and opioid use. Studies identifying strategies to prevent and manage fibromyalgia pain are needed, especially for individuals reporting comorbid insomnia and opioid use.

An evaluation of telehealth expansion in U.S. nursing homes

OBJECTIVE

This research brief contains results from a national survey about telehealth use reported in a random sample of U.S. nursing homes.

METHODS AND MATERIALS

The sample includes nursing homes (N = 664) that completed surveys about information technology maturity, including telehealth use, beginning January 1, 2019, and ending August 4, 2020. A pre/post design was employed to examine differences in nursing home telehealth use for nursing homes completing surveys prior to and after telehealth expansion, on March 6, 2020. We calculated a cumulative telehealth score using survey data from 6 questions about extent of nursing home telehealth use (score range 0-42). We calculated proportions of nursing homes using telehealth and used logistic regression to look for differences in nursing homes based on organizational characteristics and odds ratios.

RESULTS

Significant relationships were found between nursing home characteristics and telehealth use, and specifically, larger metropolitan homes reported greater telehealth use. Ownership had little effect on telehealth use. Nursing homes postexpansion used telehealth applications for resident evaluation 11.24 times more (P < .01) than did nursing homes pre-expansion.

DISCUSSION

Administrators completing our survey reported a wide range of telehealth use, including approximately 16% having no telehealth use and 5% having the maximum amount of telehealth use. Mean telehealth use scores reported by the majority of these nursing homes is on the lower end of the range.

CONCLUSIONS

One solution for the current pandemic is to encourage the proliferation of telehealth with continued relaxed regulations, which can reduce isolation and preserve limited resources (eg, personal protective equipment) while maintaining proper distancing parameters.

Foot Care Self-Management in Non-Diabetic Older Adults: A Pilot Controlled Trial

Self-management can mitigate common foot problems; however, community-dwelling older adults without diabetes rarely receive foot care self-management training. This two-group pilot study examined feasibility and preliminary efficacy of the novel, nurse-led 2 Feet 4 Life intervention. Twenty-nine adults (M age 76 years ± 6.6 years) from two senior centers completed the study (90.6% retention rate). Intervention dosage was one hour/week for four consecutive weeks. Study procedures were safe and feasible. Intervention group participants found the intervention acceptable and valuable. Observed between-group effect sizes were the following: knowledge (4.339), self-efficacy (3.652), behaviors (3.403), pain (0.375) and foot health (0.376). Large effect sizes were observed within-groups and within their interaction for knowledge (1.316), behaviors (8.430), pain (9.796), and foot health (3.778). Effect sizes suggest the intervention impacted foot care outcomes between groups and within individuals over seven months' time. Fully powered studies are indicated to test the intervention in diverse samples with more complex foot problems.

Abstract 5375: Large, polymorphonuclear circulating cancer-associated cell with dual epithelial and macrophage/myeloid phenotype is prognostic in non-small cell lung cancer and has an impact on anti-tumor immune responses

Purpose: In addition to the FDA-approved definition of a circulating tumor cell (CTC), various phenotypes of circulating cancer-associated cells have been described. A distinct large (&gt;30µm), polymorphonuclear, circulating, cancer-associated cell (CCAC) with a dual epithelial and macrophage/myeloid phenotype has been identified in solid cancer patients. Aims of the study were to identify and characterize these hybrid CCACs in non-small cell lung cancer (NSCLC) patients and to determine their impact on cancer-associated immune responses in vitro and in vivo in a murine model of lung cancer.

Experimental Design: In a prospective trial, 7.5ml of peripheral blood was collected from 167 subjects. CTCs and CCACs were enriched by size-based microfilter and immunostaining was performed (CK 8/18/19, EpCAM, CD14/45, DAPI). To mimic circulating hybrid cells, polyethylene glycol was used to induce fusion of murine RAW 264.7 macrophage cells and Lewis Lung Carcinoma (LLC) cells; fused cells were validated by flow cytometry, electron microscopy and fluorescence microscopy. Immunomodulatory effects of fused cells were determined in LLC-tumor bearing mice.

Results: 78 NSCLC patients and 89 control subjects (69 chronic smokers with and without lung nodules on screening LDCT, 20 healthy never-smokers) were enrolled. Distinct, large, polymorphonuclear CK+/EpCAM+/CD14/45+ CCACs were detected at lower rates than traditional CK+/EpCAM+/CD45- CTCs, but significantly higher in subjects with NSCLC in comparison to controls (p&lt;0.05). CCACs and traditional CTCs were absent in 20 healthy controls. ≥2 CCACs correlated with significantly poorer survival and higher recurrence rates by uni- and multivariate analysis (p&lt;0.05). To support these findings, PEG-induced fusion cells suppressed immune responses decreased T-cell activation and increased Tregs in vitro and in LLC tumor-bearing mice.

Conclusions and future perspectives: These investigations show that CCAC with a dual epithelial and macrophage/myeloid phenotype is associated with aggressive clinical behavior in NSCLC. Pro-tumorigenic mechanisms are suggested by macrophage-tumor cell fusion leading to suppressed T cell-mediated anti-tumor immune responses. In future, the impact of CCACs on tumor progression and immune responses will need to be further studied in NSCLC patients.

CCACs presentCCACs mean (±SEM); median (range)CTCs presentCTCs mean (±SEM); median (range)p valueSubjects analyzed (total)167NSCLC7861 (78.2%)3.12 (±0.37); 2 (0-17)78 (100%)21.95 (±1.24); 19 (8-80)&lt;0.05† (CCACs vs. CTCs)Median Age (range)69 (41-81)Gender• Females (%)41 (52.6%)• Males (%)37 (47.4%)Stage (AJCC 8th ed.)&lt;0.05* (CCACs vs. CTCs)• I39 (50%)26 (66.7%)1.26 (±0.21); 1 (0-5)39 (100%)14.59 (±0.62); 14 (8-28)• II15 (19.2%)11 (73.3%)2.67 (±0.64); 2 (0-7)15 (100%)22.67 (±1.12); 23 (18-33)• III12 (15.4%)12 (100%)6.17 (±0.81); 6 (2-11)12 (100%)29.42 (±1.58); 29 (23-42)• IV12 (15.4%)12 (100%)6.67 (±1.21); 5 (3-17)12 (100%)37.5 (±4.23); 36 (25-80)(p&lt;0.05*)(p&lt;0.05*)Control long-term smoker subjects69Median Age (range)63 (54-74)Gender• Females (%)32 (46.4%)• Males (%)37 (53.6%)No lung nodules14007 (50%)1.36 (±0.45); 0 (0-4)Benign lung nodules5511 (20%)0.33 (±0.09); 0 (0-2)41 (74.5%)3.26 (±0.39); 3 (0-11)Healthy, never-smoker controls200 (0%)00 (0%)0

Citation Format: Yariswamy Manjunath, Kanve N. Suvilesh, Diego M. Avella, Eric T. Kimchi, Kevin F. Staveley-O'Carroll, Chelsea B. Deroche, Guangfu Li, Jussuf T. Kaifi. Large, polymorphonuclear circulating cancer-associated cell with dual epithelial and macrophage/myeloid phenotype is prognostic in non-small cell lung cancer and has an impact on anti-tumor immune responses [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5375.

Abstract B28: Large and polymorphonuclear circulating cancer-associated cell with dual epithelial and macrophage/myeloid phenotype as a liquid biomarker in non-small cell lung cancer patients

Purpose: In addition to the FDA-approved definition of a circulating tumor cell (CTC), various phenotypes of circulating cancer-associated cells in the blood have been described. A distinct large (&gt;30μm), polymorphonuclear, circulating, cancer-associated cell (CCAC) with a dual epithelial and macrophage/myeloid phenotype has been identified in solid cancer patients. The goal of the study was to identify and further characterize these hybrid CCACs in non-small cell lung cancer (NSCLC) patients.

Experimental Design: In a prospective trial, 7.5 mL of peripheral blood was collected from 167 subjects. CTCs and CCACs were isolated by size-based exclusion with a microfilter and immunofluorescence staining was performed (cytokeratin (CK) 8/18/19, EpCAM, CD14/45, DAPI).

Results: 78 NSCLC patients and 89 control subjects (69 chronic smokers with and without lung nodules on screening LDCT, 20 healthy never-smokers) were enrolled. Distinct, large, polymorphonuclear CKpos/EpCAMpos/CD14/45pos CCACs were detected at lower rates than traditional CKpos/EpCAMpos/CD45negCTCs, but significantly higher in subjects with NSCLC in comparison to controls (p&lt;0.05). These cells and traditional CTCs were absent in 20 healthy controls. In contrast to CTCs, counts of large and polymorphonuclear CCACs were not associated with tumor stages. However, ≥2 CCACs correlated with significantly poorer survival and higher recurrence rates by uni- and multivariate analysis (p&lt;0.05).

Conclusions and Future Perspectives: This study shows that in addition to CTCs, a distinct, large, polymorphonuclear CCAC with a dual epithelial and macrophage/myeloid phenotype is associated with an aggressive clinical behavior in NSCLC patients. The biologic role of these unique cells will need to be further investigated, as these may have a potential impact on the immune response towards the cancer.

Citation Format: Yariswamy Manjunath, Diego M. Avella, Eric T. Kimchi, Kevin F. Staveley-O'Carroll, Chelsea B. Deroche, Gunagfu Li, Jussuf T. Kaifi. Large and polymorphonuclear circulating cancer-associated cell with dual epithelial and macrophage/myeloid phenotype as a liquid biomarker in non-small cell lung cancer patients [abstract]. In: Proceedings of the AACR Special Conference on Advances in Liquid Biopsies; Jan 13-16, 2020; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(11_Suppl):Abstract nr B28.

18F-FDG PET/CT total lesion glycolysis is associated with circulating tumor cell counts in patients with stage I to IIIA non-small cell lung cancer

Background

In non-small cell lung cancer (NSCLC), ¹⁸F-fluoro-2-deoxy-D-glucose (¹⁸F-FDG) uptake determined by PET and presence of circulating tumor cells (CTCs) in the peripheral blood independently predict outcomes. For ¹⁸F-FDG PET/CT staging interpretation, standardized uptake values (SUV_max/avg) are routinely used in clinical reporting. The goal was to investigate whether ¹⁸F-FDG uptake measured by SUV_max/avg, but also measures of metabolic tumor volume (MTV) and total lesion glycolysis (TLG) (MTV × SUV_avg), are associated with CTCs.

Methods

Prospectively, 7.5 mL blood was drawn from NSCLC patients at the time of staging 18F-FDG PET/CT and from healthy control subjects. CTCs were identified by immunofluorescent staining (CK8/18/19^pos/EpCAM^pos/CD45^neg/DAPI^pos nucleus). ¹⁸F-FDG PET/CTs were analyzed for SUV_max, SUV_avg, MTV, and TLG.

Results

In 16 NSCLC patients with stage I–IIIA, MTV and TLG, in contrast to SUV_max and SUV_avg, were positively associated with CTCs (linear regression analysis). No CTCs were detectable in 20 healthy control subjects.

Conclusions

This pilot study demonstrates that ¹⁸F-FDG PET/CT TLG correlates with CTCs in NSCLC patients without distant metastases. TLG might be a more appropriate marker for hematogenous micrometastatic potential than SUVs.

0501 Development and Initial Evaluation of Web-Based Cognitive Behavioral Therapy for Insomnia “Nitecapp” in Rural Dementia Caregivers: A Mixed-Methods Study

Introduction

Informal caregivers (CGs) of persons with dementia frequently experience insomnia. The time consuming and unpredictable schedule of CGs, and associated emotional/physical exhaustion emphasize the need for brief, easily accessible interventions to treat insomnia. Internet-based behavioral insomnia interventions hold promise, particularly for rural CGs who have limited access to traditional in-person treatments. This study aimed to 1) translate an efficacious 4 session cognitive behavioral therapy for insomnia (CBT-I) to web-based “NiteCAPP” for dementia caregivers, and 2) conduct NiteCAPP usability testing/evaluate acceptability of content and features.

Methods

NiteCAPP is an online CBT-I that incorporates guided delivery through weekly therapist moderator feedback. A stepwise approach was implemented in order to explore user needs and validate NiteCAPP content in a focus group of rural dementia caregivers (n=5) and primary care providers (PCPs; n=5). Participants conducted usability testing and provided ratings of program content (1-least favorable to 5-most favorable) regarding ease of use, amount of information, website maintaining interest, adequate font size, videos maintaining interest/easy to understand/helpful. Participants also indicated whether they had at home internet access, method of internet access, and provided open ended feedback on NiteCAPP. Feedback transcripts were compiled and analyzed independently (C.S.M., A.F.C.) through deductive content analysis. Topics mentioned frequently were categorized and merged into common themes during consensus meeting, and NiteCAPP was subsequently adapted.

Results

Average ratings for NiteCAPP features were high, ranging from 4.1/5 to 4.7/5 across all items. All participants had access to internet through both phone and computer. No barriers to use identified. Feedback themes were largely positive (e.g., comprehensive written material, promotes independence, excellent visual tools for therapy moderator feedback, good pacing, use of visual contrast). Negative themes for improvement/adaptation included adding font size options, a light/dark mode, tab with all videos, reducing amount of scrolling, adding a glossary of terms.

Conclusion

Rural dementia CGs and PCPs evaluated NiteCAPP as easy to use with acceptable features and program content and no barriers to access. Improvement themes were used to adapt NiteCAPP. Next steps are to evaluate feasibility and preliminary efficacy of NiteCAPP in rural dementia CGs with insomnia.

Support

none

0922 Nightly Associations Between Pre-Bedtime Activity, Actigraphic Light, and Sleep in Children With ASD and Insomnia

Introduction

Approximately two thirds of children with Autism Spectrum Disorder (ASD) suffer from chronic insomnia. Current behavioral interventions for insomnia in children with ASD use sleep hygiene guidelines to educate parents and their children regarding sleep promoting habits. However, the relationship between pre-bedtime physical activity/light and sleep is understudied in ASD. The current study examined daily associations between pre-bedtime actigraphically assessed activity/light levels and objective/subjective sleep outcomes in children with ASD and insomnia.

Methods

Thirty children (Mage=8.5 yrs, SD=1.78 yrs) with comorbid ASD and insomnia completed 14 days of actigraphy measuring ambient white light intensity and activity levels every 30 seconds. Validated sleep scoring algorithms (in Actiware V. 6.0.9) estimated objective sleep onset latency (SOL), total sleep time (TST), wake time after sleep onset (WASO), and average activity/light levels 30, 60, and 120 mins prior to bedtime. Additionally, average activity/light levels 120-240, and 240-360 mins prior to bedtime were computed. Children also completed 14 daily sleep diaries (with parental assistance) measuring subjective reports of the same sleep parameters. Associations between daily estimations of pre-bedtime activity levels, light, and nighttime objective and subjective sleep were examined through multilevel modelling. Bonferroni corrections were performed to account for multiple comparisons.

Results

After Bonferroni corrections (p&lt;.025 significance level), greater activity within 30 minutes (B=0.0465, p=.0093) and 60 minutes (B=0.0681, p=.0005) of bedtime were associated with longer subjective SOL. Pre-bedtime light exposure was not a significant predictor of sleep outcomes.

Conclusion

Results suggest that in general, variations in daily pre-bedtime activity, but not light, are associated with worse nightly subjective SOL in children with ASD and insomnia. Findings support that sleep hygiene recommendations in children with ASD include avoidance of higher levels of pre-sleep physical activity. Prospective studies examining temporal causal relationships between pre-bedtime activity and sleep in ASD are warranted.

Support

Research was supported by a University of Missouri Research Board award (McCrae, PI; Mazurek, Co-PI). Data collected as part of clinical trial NCT02755051 Targeting Sleep in Kids with Autism Spectrum Disorder at the University of Missouri (PI: McCrae).

Excluding Pulmonary Embolism with End-tidal Carbon Dioxide: Accuracy, Cost, and Harm Avoidance

A non-randomized single center prospective, descriptive, correlational design was used to determine what end-tidal carbon dioxide (EtCO₂) level provided the best sensitivity, specificity, and negative predictive value to exclude pulmonary embolism (PE) diagnosis in hemodynamically stable hospitalized adults (n = 111). The financial impact and harm avoidance of adding EtCO₂ to the PE diagnostic process also were examined. PE diagnosis was determined by computed tomography pulmonary angiography (CTPA). PE prevalence was 18.9%. Mean±SD EtCO₂ was lower for PE positive than negative participants (28 ± 7.8 to 33 ± 8.1 mmHg respectively 95% CI: 1.22-8.96; P = .01). For PE exclusion, an EtCO₂ cutoff ≥42 mmHg yielded 100% sensitivity, 12.2% specificity, and 100% negative predictive value. For every six inpatients assessed with EtCO₂, one could be saved from unnecessary CTPA. Eliminating unnecessary CTPA removes the potential harm associated with radiation and intravenous contrast exposure. Additionally, an EtCO₂ cutoff ≥42 mmHg could eliminate ~$88,000/year in healthcare waste at this institution.

Exploring Resident Care Information Technology Use and Nursing Home Quality

A wide array of sophisticated information technology (IT) systems are being used in nursing home (NH) resident care to improve quality. The purpose of the current study was to explore differences in NH IT sophistication, a comprehensive measure of adoption, used in resident care processes based on facility characteristics over 4 consecutive years and to examine the impact on select long-stay NH quality measures. Results indicate IT systems used in resident care are becoming increasingly sophisticated. NH bed size, type of ownership, and location were significant predictors of IT score in areas related to resident care. Results also suggest that as electronic clinical processes and documents increase (e.g., incident reporting, nursing flowsheets, care planning) in resident care, more falls with injury are detected. Continued assessments of NH IT sophistication are important as the impact of technology on quality continues to be evaluated. [Journal of Gerontological Nursing, 46(4), 15-20.].

Health Data Sharing in US Nursing Homes: A Mixed Methods Study

OBJECTIVES

(1) To understand the extent to which nursing homes have the capability for data sharing and (2) to explore nursing home leaders' perceptions of data sharing with other health care facilities and with residents and family members.

DESIGN

Exploratory, mixed-methods.

SETTING AND PARTICIPANTS

We conducted a secondary analysis of data from a national survey of nursing home administrative leaders (n = 815) representing every state in the United States. Next, semistructured interviews were used to elicit rich contextual information from (n = 12) administrators from nursing homes with varying data-sharing capabilities.

METHODS

We used descriptive statistics along with Rao-Scott chi-square and logistic regression models to examine the relationship between health data-sharing capabilities and nursing home characteristics such as location, bed size, and type of ownership. Qualitative data were analyzed using content analysis.

RESULTS

Of the 815 nursing homes completing the survey, 95% had computerized (electronic) medical records, and 46% had some capability for health information exchange. Nursing homes located in metropolitan areas had 2.53 (95% confidence interval = 1.53, 4.18) times greater odds for having health information exchange capability compared with nursing homes in small towns. Perceived challenges to health data sharing with residents and family members and external clinical partners include variance in systems and software, privacy and security concerns, and organizational factors slowing uptake of technology. Perceived benefits of health data sharing included improved communication, improved care planning, and anticipating future demand.

CONCLUSIONS AND IMPLICATIONS

As health data sharing becomes more ubiquitous in acute care settings, policy makers, nursing home leaders, and other stakeholders should prepare by working to mitigate barriers and capitalize on potential benefits of implementing this technology in nursing homes.

Body mass index trends and quality of life from breast cancer diagnosis through seven years’ survivorship

BACKGROUND

Weight gain is a potential negative outcome of breast-cancer treatment, occurring in 50%-to-96% of breast-cancer patients, although the amount of weight gain is inconsistently reported in the literature. Research has also shown a relationship between overweight/obesity and breast-cancer mortality. Correspondingly, weight management is a self-care approach known to benefit quality of life (QOL). These research questions and analysis add to existing literature by examining participants’ body mass index (BMI) trend and its relationship with QOL indicators over seven years.

AIM

To examine: (1) BMI trends among breast cancer survivors; and (2) The trends’ relationship to QOL indicators over seven years.

METHODS

During the Breast Cancer and Lymphedema Project, 378 patients’ weight and height were recorded by nurses prior to or just after beginning breast cancer treatment and repeated at quarterly-to-semiannual intervals over seven years. Additionally, participants annually completed the 36-Item Short Form Health Survey (SF-36), a valid and reliable tool assessing QOL and health concepts, including physical function, pain, and emotional well-being. BMI trends, change in BMI, and change in SF-36 subscales over seven years were calculated using a random-intercept repeated-measures regression. Patients were placed into BMI categories at each time point: Normal, Overweight and Obese. As patients’ weights changed, they were categorized accordingly.

RESULTS

During the seven-year study and while controlling for age and residence, participants gained an average of 0.3534 kg/m² (P = 0.0009). This amount remained fairly consistent across BMI categories with those in the normal-weight category (n = 134) gaining 0.4546 kg/m² (P = 0.0003); Overweight (n = 190) gaining 0.2985 kg/m² (P = 0.0123); and obese (n = 199) gaining 0.3147 kg/m², (P = 0.0649). Age (under or over 55) and region (metro/micro vs small/rural) were significantly associated with BMI increase in both the normal and obese categories. There were statistically significant (P < 0.0100) changes in five of the eight SF-36 domains; however, the directions of change were different and somewhat divergent from that hypothesized. Controlling for age and region, these five were statistically significant, so there were no change or differences between the micropolitan/metropolitan and small town/rural groups.

CONCLUSION

Although only modest increases in mean BMI were observed, mean BMI change was associated with selected QOL indicators, suggesting the continued need for self-care emphasis during breast cancer survivorship.

Adherence to Short-course Pharmacotherapy in Adults with Irritable Bowel Syndrome

Irritable Bowel Syndrome (IBS), characterized by abdominal pain and bowel dysfunction, treatment focuses on alleviating symptoms. Adherence is crucial for pharmacologic management success. We examined 73 adult's objective adherence to rifaximin using the taxonomy for adherence. Demographic, quality of life (QOL), psychological distress, perceived stress, adverse childhood experiences (ACE), pain, and adherence data were collected. Impaired QOL, elevated psychological distress and perceived stress, and a significant number of ACE were reported at baseline. Average time to prescription initiation was 2.5 days. Once implemented, 92% missed midday dose and persisted 5 days beyond the prescribed dose. High-adherers reported lower pain levels post-rifaximin compared to low-adherers. Objective adherence was significantly lower than self-reported. Objective adherence was not predicted by above variables. Adherence to rifaximin is poor in those with IBS. Future research examining perceived barriers/facilitators toward rifaximin adherence may provide insight into patient-centered, modifiable targets for adherence interventions and improve patient-related outcomes.

Ternary Trends in Nursing Home Information Technology and Quality Measures in the United States

Nursing home information technology (NH IT) adoption trends are not measured regularly. Evidence indicates digital footprints are growing, but gaps about NH IT adoption and quality impacts remain. We hypothesize as NH IT adoption grows, quality improves. This research assessed ternary (2014-2017) trends in IT and quality measures using a primary survey of U.S. NHs. Survey measures included nine dimensions/domains and total IT sophistication. Administrators completed 815 Year 1 surveys. Each year mean total IT sophistication scores in nine dimensions/domains consistently increased. Eighteen significant correlations (r > .13, absolute value) between IT sophistication and quality measures existed. Regression shows that for every 10 units increase in administrative activity extent of IT use, a decrease of 1.3% occurs in the percentage of low-risk long-stay residents with bowel or bladder incontinence. Increases in NH IT sophistication positively impact quality. Estimating ongoing trends in NH IT sophistication provides new information that should be consistently available.

Building consensus toward a national nursing home information technology maturity model

OBJECTIVES

We describe the development of a nursing home information technology (IT) maturity model designed to capture stages of IT maturity.

MATERIALS AND METHODS

This study had 2 phases. The purpose of phase I was to develop a preliminary nursing home IT maturity model. Phase II involved 3 rounds of questionnaires administered to a Delphi panel of expert nursing home administrators to evaluate the validity of the nursing home IT maturity model proposed in phase I.

RESULTS

All participants (n = 31) completed Delphi rounds 1-3. Over the 3 Delphi rounds, the nursing home IT maturity staging model evolved from a preliminary, 5-stage model (stages 1-5) to a 7-stage model (stages 0-6).

DISCUSSION

Using innovative IT to improve patient outcomes has become a broad goal across healthcare settings, including nursing homes. Understanding the relationship between IT sophistication and quality performance in nursing homes relies on recognizing the spectrum of nursing home IT maturity that exists and how IT matures over time. Currently, no universally accepted nursing home IT maturity model exists to trend IT adoption and determine the impact of increasing IT maturity on quality.

CONCLUSIONS

A 7-stage nursing home IT maturity staging model was successfully developed with input from a nationally representative sample of U.S. based nursing home experts. The model incorporates 7-stages of IT maturity ranging from stage 0 (nonexistent IT solutions or electronic medical record) to stage 6 (use of data by resident or resident representative to generate clinical data and drive self-management).

Early Maturity as the New Normal: A Century-long Study of Bone Age

BACKGROUND

Epiphyseal fusion (EF) marks the completion of longitudinal bone growth, a critical milestone monitored during treatment of skeletal growth and/or developmental disorders. Recently, a trend toward accelerated skeletal maturation in children has been documented. Because current methods for assessing skeletal maturation include children in their reference populations born as early as the 1930s, the timing of EF events in contemporary patients may differ substantially from those standards.

QUESTIONS/PURPOSES

(1) Do children today initiate the process of EF in the hand and wrist earlier than past generations on which maturity standards are based? (2) Do children today complete EF in the hand and wrist earlier than past generations on which maturity standards are based?

METHODS

A total of 1292 children (665 males, 627 females) participating in the Fels Longitudinal Study, born between 1915 and 2006, were included in this retrospective, observational study. Each participant had between one and 39 serial left hand-wrist radiographs during childhood obtained specifically for research purposes. Main outcomes were the chronological age at the first sign of EF initiation (EF-I) and the first chronological age when EF was complete (EF-C) in the radius and ulna, and metacarpals and phalanges of the first, third, and fifth rays according to criteria of the Fels method. EF is a reliable metric with an average κ agreement statistic of 0.91. Penalized B-splines were used to model the changes in EF-I and EF-C ages and to identify changes across continuous birth years with major comparisons between children born in 1935 and 1995.

RESULTS

Approximately half of the epiphyses of the hand and wrist examined exhibited earlier EF-I and/or earlier EF-C in children born in 1995 compared with those born in 1935. The age at each milestone (EF-I and EF-C) decreased by as much as 6.7 and 6.8 months in males and 9.8 and 9.7 months in females, respectively. This change occurred gradually over the past century. The more proximal traits (EF of the distal radius, distal ulna, and metacarpals) were more likely to experience a shift in timing, whereas timing of EF in the phalanges remained relatively stable across birth years.

CONCLUSIONS

A trend has occurred over the past century in the timing of EF, in both initiation and completion of the process, for many of the bones of the hand and wrist. Earlier EF reflects modern population advances in both skeletal and sexual maturation. Shifts in the timing of EF have the potential to influence treatment strategies for skeletal growth and/or developmental disorders such as scoliosis or leg length inequality, moving treatment windows to earlier ages. Earlier EF-I and EF-C identified in this study signals a need to reevaluate the timing of maturational milestones and current standards for skeletal assessment.

LEVEL OF EVIDENCE

Level II, prognostic study.

Randomized Trial of Intelligent Sensor System for Early Illness Alerts in Senior Housing

OBJECTIVES

Measure the clinical effectiveness and cost effectiveness of using sensor data from an environmentally embedded sensor system for early illness recognition. This sensor system has demonstrated in pilot studies to detect changes in function and in chronic diseases or acute illnesses on average 10 days to 2 weeks before usual assessment methods or self-reports of illness.

DESIGN

Prospective intervention study in 13 assisted living (AL) communities of 171 residents randomly assigned to intervention (n=86) or comparison group (n=85) receiving usual care.

METHODS

Intervention participants lived with the sensor system an average of one year.

MEASUREMENTS

Continuous data collected 24 hours/7 days a week from motion sensors to measure overall activity, an under mattress bed sensor to capture respiration, pulse, and restlessness as people sleep, and a gait sensor that continuously measures gait speed, stride length and time, and automatically assess for increasing fall risk as the person walks around the apartment. Continuously running computer algorithms are applied to the sensor data and send health alerts to staff when there are changes in sensor data patterns.

RESULTS

The randomized comparison group functionally declined more rapidly than the intervention group. Walking speed and several measures from GaitRite, velocity, step length left and right, stride length left and right, and the fall risk measure of functional ambulation profile (FAP) all had clinically significant changes. The walking speed increase (worse) and velocity decline (worse) of 0.073 m/s for comparison group exceeded 0.05 m/s, a value considered to be a minimum clinically important difference. No differences were measured in health care costs.

CONCLUSIONS

These findings demonstrate that sensor data with health alerts and fall alerts sent to AL nursing staff can be an effective strategy to detect and intervene in early signs of illness or functional decline.

Colorectal Cancer Screening Adherence in Selected Disabilities Over 10 Years

INTRODUCTION

Colorectal cancer (CRC) is the second leading cause of cancer mortality in the U.S.; however, if the population aged 50 years or older received routine screening, approximately 60% of these deaths could be eliminated. This study investigates whether adults, aged 50-75 years, with one of three disabilities (blind/low vision [BLV], intellectual disability [ID], spinal cord injury [SCI]) receive CRC screening at rates equivalent to adults without the three disabilities, by accounting for combinations of recommended CRC screenings during a 10-year period (colonoscopy, sigmoidoscopy, fecal occult blood test).

METHODS

South Carolina Medicaid and Medicare, State Health Plan, and hospital discharge data (2000-2009) were analyzed (2013-2015) to estimate the proportion of adherence to and adjusted odds of CRC screening over time among adults with one of the three disabilities, BLV, ID, or SCI, versus adults without these conditions.

RESULTS

The estimated proportion of adults who adhere to changing recommendations over time was lower for adults with ID (34.32%) or SCI (44.14%) compared with those without these disabilities (48.48%). All three case groups had significantly lower AORs of adherence versus those without (BLV: AOR=0.88, 95% CI=0.80, 0.96; ID: AOR=0.55, 95% CI=0.52, 0.59; SCI: AOR=0.88, 95% CI=0.82, 0.95).

CONCLUSIONS

In this study, adults with BLV, ID, or SCI were less likely to receive and adhere to CRC screening recommendations than those without these disabilities. This method provides a thorough evaluation of adherence to CRC screening by considering levels of adherence during each month of Medicaid or Medicare coverage.

Pharmacotherapy effectiveness for clinical subgroups among children and adolescents with early onset schizophrenia

OBJECTIVE

This study aims to determine the effectiveness of pharmacotherapies among children and adolescents diagnosed with early onset schizophrenia subgrouped according to their co-occurring psychiatric disorders.

METHODS

A retrospective cohort design was employed, using South Carolina's (USA) Medicaid claims dataset covering outpatient and inpatient medical services, between January, 1999 and December, 2013 to identify patients ≤17 years of age. Random effects regression analyses assessed differential changes in acute psychiatric service utilization over time across the 3 subgroups associated with antipsychotic, mood stabilizer, psychostimulant, or antidepressant pharmacotherapy.

RESULTS

For patients with schizophrenia and comorbid mood disorders or emotional dysregulation (Cluster 1), or schizophrenia and severe cognitive impairments (Cluster 2), those treated with monotherapy second-generation antipsychotics (SGAs) over time demonstrated consistently lower use of acute psychiatric treatment services as did those coprescribed mood stabilizers, primarily lithium, or anticonvulsants. In all clusters, including the relatively homogenous subgroup of patients with early onset schizophrenia and few comorbid disorders, acute psychiatric service utilization was significantly higher and more variable over time for those prescribed multiple SGAs.

CONCLUSIONS

Regardless of the specific constellation of symptoms and comorbid disorders targeted, the coprescription of multiple SGAs was not effective over time in stabilizing children and adolescents outside of acute care settings.

Diagnostic clusters associated with an early onset schizophrenia diagnosis among children and adolescents

OBJECTIVE

Given the greater severity and chronicity of psychiatric disorders that first declare in individuals under the age of 18, early onset schizophrenia (EOS) and its association with co-occurring psychiatric conditions deserve further investigation.

METHODS

Cluster and discriminant analyses were used to examine the heterogeneity of children and adolescents diagnosed with schizophrenia in 1 statewide system of care. A retrospective cohort design was employed, using South Carolina's (USA) Medicaid claims dataset covering outpatient and inpatient medical services between January, 1999 and December, 2013 to identify patients ≤17 years of age.

RESULTS

Among the 613 EOS patients selected, 3 main clusters of ICD-9 psychiatric diagnoses were identified: (1) older children with schizophrenia coaggregated with a spectrum of mood/emotional dysregulation conditions; (2) younger children with coaggregated schizophrenia, mental retardation/intellectual disability or autism spectrum disorders; and (3) older children with schizophrenia and significantly fewer diagnosed co-occurring conditions. Externalizing/disruptive behavior disorders (i.e., attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder) were significantly associated with Clusters 1 and 2.

CONCLUSION

Symptom patterns plus age of first diagnosis are important differentiators of EOS subgroups in this cohort. Earlier recognition of psychiatric symptom/syndrome patterns that frequently co-occur may enable clinicians to stratify/tailor treatment interventions.

Adherence to US Preventive Services Task Force recommendations for breast and cervical cancer screening for women who have a spinal cord injury

CONTEXT

Women with spinal cord injury (SCI) may face barriers that result in disparities in receipt of recommended mammography and Papanicolaou testing.

SETTING

South Carolina.

PARTICIPANTS

South Carolina women with SCI were identified using International Classification of Diseases codes in 2000-2010 Medicaid and Medicare billing data.

OUTCOME MEASURES

Receipt of mammography and Pap testing was determined using procedure billing codes. Partial proportional odds models were estimated to examine the association between SCI and adherence with screening recommendations from the United States Preventive Services Task Force. Each individual's screening experience was classified as full adherence, partial adherence, or no screening.

RESULTS

The cohort for mammography consisted of 3,173 women with SCI and 6,433 comparison women without SCI. The cohort for Pap testing consisted 5,025 women with SCI and 9,538 comparison women. Women with SCI were less likely to have full adherence with mammography recommendations (aOR = 0.69, 95% CI 0.64, 0.76) and Pap test recommendations (aOR = 0.53, 95% CI 0.49, 0.57). They were more likely to have no mammography screening (aOR = 1.44, 95% CI 1.33, 1.57) and no Pap testing (aOR = 1.89, 95% CI 1.77, 2.03) than women without SCI.

CONCLUSION

Using longitudinal data with multiple outcome levels, women with SCI were less likely to be fully adherent with receipt of recommended breast and cervical cancer screenings and more likely to have no screenings during the eligible years when compared to women without SCI.

Development of a tool to describe overall health, social independence and activity limitation of adolescents and young adults with disability

There is a need for research that focuses on the correlation between self-perceived quality of life (QoL) and the health outcomes of adolescents with disability transitioning to adulthood. To better understand the transition experience of adolescents and young adults with disability, we developed a questionnaire to assess the impact of disability on QoL. We recruited 174 participants who were 15-24 years old and diagnosed with Fragile X syndrome (FXS), spina bifida (SB) or muscular dystrophy (MD) and conducted an exploratory factor analysis to identify factors that characterize QoL. Five factors emerged: emotional health, physical health, independence, activity limitation, and community participation. To validate the tool, we linked medical claims and other administrative data records and examined the association of the factor scores with health care utilization and found the questionnaire can be utilized among diverse groups of young people with disability.

Is prepregnancy obesity associated with risk of cerebral palsy and epilepsy in children?

We conducted a retrospective cohort study to investigate the association between prepregnancy obesity in women and risk of cerebral palsy and epilepsy in their children using data from the South Carolina Medicaid program. The cohort included 83,901 maternal-child pairs; 100 cases of cerebral palsy were initially identified, followed by 53 cases that had at least 2 cerebral palsy diagnoses. For confirmed epilepsy, diagnosed on at least 5 occasions or by more than 1 provider, 83,472 observations were included with 338 cases. There was no association between maternal body mass index and risk of childhood epilepsy. A significant association between increasing maternal body mass index and any diagnosis of cerebral palsy was found, and morbid obesity was associated with increased risk of any and confirmed cerebral palsy. In conclusion, there appears to be an association of maternal body mass index with cerebral palsy, but there is no evidence to support an association with epilepsy.

Reproductive efficiency of captive Chinese- and Indian-origin rhesus macaque (Macaca mulatta) females

Reproductive and survival records (n=2,913) from 313 Chinese-origin and 365 Indian-derived rhesus macaques at the Tulane National Primate Research Center (TNPRC) spanning three generations were studied. Least-squares analysis of variance procedures were used to compare reproductive and infant survival traits while proportional hazards regression procedures were used to study female age at death, number of infants born per female, and time from last birth to death. Chinese females were older at first parturition than Indian females because they were older when placed with males, but the two subspecies had similar first postpartum birth interval (1st PPBI) and lifetime postpartum birth interval (LPPBI). Females that gave birth to stillborn infants had shorter first postpartum birth intervals (1st PPBI) than females giving birth to live infants. Postpartum birth intervals decreased in females from age 3 to 12 but then increased again with advancing age. Chinese infants had a greater survival rate than Indian infants at 30 days, 6 months, and 1 year of age. Five hundred and forty-three females (80.01%) had uncensored, or true records for age at death, number of infants born per female, and time from the birth until death whereas 135 females (19.91%) had censored records for these traits. Low- and high-uncensored observations for age at death were 3 and 26 years for Chinese, and 3 and 23 years for Indian females. Uncensored number of infants born per female ranged from 1 to 15 for Chinese females and 1 to 18 for Indian females. Each of these traits was significantly influenced by the origin×generation interaction in the proportional hazards regression analyses, indicating that probabilities associated with age at death, number of infants born per female, and time from last birth to death for Chinese and Indian females did not rank the same across generations.