A cluster-randomized controlled trial of a multicomponent intervention protocol for pneumonia prevention among nursing home elders

BACKGROUND

Pneumonia remains an important public health problem among elderly nursing home residents. This clinical trial sought to determine if a multicomponent intervention protocol, including manual tooth/gum brushing plus 0.12% chlorhexidine oral rinse, twice per day, plus upright positioning during feeding, could reduce the incidence of radiographically documented pneumonia among nursing home residents, compared with usual care.

METHODS

This cluster-randomized clinical trial was conducted in 36 nursing homes in Connecticut. Eligible residents >65 years with at least 1 of 2 modifiable risk factors for pneumonia (ie, impaired oral hygiene, swallowing difficulty) were enrolled. Nursing homes were randomized to the multicomponent intervention protocol or usual care. Participants were followed for up to 2.5 years for development of the primary outcome, a radiographically documented pneumonia, and secondary outcome, a lower respiratory tract infection (LRTI) without radiographic documentation.

RESULTS

A total of 834 participants were enrolled: 434 to intervention and 400 to usual care. The trial was terminated for futility. The number of participants in the intervention vs control arms with first pneumonia was 119 (27.4%) vs 94 (23.5%), respectively, and with first LRTI, 125 (28.8%) vs 100 (25.0%), respectively. In a multivariable Cox regression model, the hazard ratio in the intervention vs control arms, respectively, was 1.12 (95% confidence interval [CI], .84-1.50; P = .44) for first pneumonia and 1.07 (95% CI, .79-1.46, P = .65) for first LRTI.

CONCLUSIONS

The multicomponent intervention protocol did not significantly reduce the incidence of first radiographically confirmed pneumonia or LRTI compared with usual care in nursing home residents.

CLINICAL TRIALS REGISTRATION

NCT00975780.

Lifestyle interventions and independence for elders study: recruitment and baseline characteristics

BACKGROUND

Recruitment of older adults into long-term clinical trials involving behavioral interventions is a significant challenge. The Lifestyle Interventions and Independence for Elders (LIFE) Study is a Phase 3 multicenter randomized controlled multisite trial, designed to compare the effects of a moderate-intensity physical activity program with a successful aging health education program on the incidence of major mobility disability (the inability to walk 400 m) in sedentary adults aged 70-89 years, who were at high risk for mobility disability (scoring ≤ 9 on the Short Physical Performance Battery) at baseline.

METHODS

Recruitment methods, yields, efficiency, and costs are described together with a summary of participant baseline characteristics. Yields were examined across levels of sex, race and ethnicity, and Short Physical Performance Battery, as well as by site.

RESULTS

The 21-month recruiting period resulted in 14,812 telephone screens; 1,635 participants were randomized (67.2% women, 21.0% minorities, 44.7% with Short Physical Performance Battery scores ≤ 7). Of the telephone-screened participants, 37.6% were excluded primarily because of regular participation in physical activity, health exclusions, or self-reported mobility disability. Direct mailing was the most productive recruitment strategy (59.5% of randomized participants). Recruitment costs were $840 per randomized participant. Yields differed by sex and Short Physical Performance Battery. We accrued 11% more participant follow-up time than expected during the recruitment period as a result of the accelerated recruitment rate.

CONCLUSIONS

The LIFE Study achieved all recruitment benchmarks. Bulk mailing is an efficient method for recruiting high-risk community-dwelling older persons (including minorities), from diverse geographic areas for this long-term behavioral trial.

Impact of double counting and transfer bias on estimated rates and outcomes of acute myocardial infarction

CONTEXT

Ischemic heart disease is the leading cause of death in the United States. Recent studies report inconsistent findings on the changes in the incidence of hospitalizations for ischemic heart disease. These reports have relied primarily on hospital discharge data. Preliminary data suggest that a significant percentage of patients suffering acute myocardial infarction (MI) in rural communities are transferred to urban centers for care. Patients transferred to a second hospital may be counted twice for one episode of ischemic heart disease.

OBJECTIVE

To describe the impact of double counting and transfer bias on the estimation of incidence rates and outcomes of ischemic heart disease, specifically acute MI, in the United States.

DESIGN

Analysis of state hospital discharge data from Kansas, Colorado (State Inpatient Database [SID]), Nebraska, Arizona, New Jersey, Michigan, Pennsylvania, and Illinois (SID) for the years 1995 to 1997. A matching algorithm was developed for hospital discharges to determine patients counted twice for one episode of ischemic heart disease. Validation of our matching algorithm.

PATIENTS

Patients reported to have suffered ischemic heart disease (ICD9 codes 410-414, 786.5).

MAIN OUTCOME MEASURES

Number of patients counted twice for one episode of acute MI.

RESULTS

It is estimated that double count rates range from 10% to 15% for all states and increased over the 3 years. Moderate sized rural counties had the highest estimated double count rates at 15% to 20% with a few counties having estimated double count rates a high as 35% to 50%. Older patients and females were less likely to be double counted (P <0.05).

CONCLUSIONS

Double counting patients has resulted in a significant overestimation in the incidence rate for hospitalization for acute MI. Correction of this double counting reveals a significantly lower incidence rate and a higher in-hospital mortality rate for acute MI. Transferred patients differ significantly from nontransferred patients, introducing significant bias into MI outcome studies. Double counting and transfer bias should be considered when conducting and interpreting research on ischemic heart disease, particularly in rural regions.

Matching anonymous pre-posttests using subject-generated information

Sensitive research issues call for anonymous questionnaires. This makes accurately matching pretests with posttests difficult or impossible. Various subject-generated coding schemes have been developed, but their accuracy has been unknown. This anonymous study, with 745 students, used subject-generated coding to match pretests with posttests. The matching was verified for accuracy with the use of a collateral, anonymous, sticker identification system. The coding system was able to accurately match 75.2% of all the pretest-posttest pairs. An additional 22.1% of the pairs were left unmatched and only 2.7% were matched incorrectly. Subject-generated coding systems can be very effective where confidentiality is important to protect.

Preventing HIV infection among adolescents: evaluation of a school-based education program

BACKGROUND

This article reports the results of the impact of a school-based HIV prevention intervention on students' knowledge, attitudes, and behavior related to HIV infection.

METHODS

Seventeen schools within six Colorado school districts were assigned to either intervention or comparison conditions. Students in 10 schools received a 15-session, skills-based HIV prevention curriculum implemented by trained teachers. A total of 2,844 students completed at least one survey during the study period; surveys were matched using demographic questions, yielding a cohort of 979 students who had baseline and 6-month follow-up data.

RESULTS

Intervention students exhibited greater knowledge about HIV and greater intent to engage in safer sexual practices than the comparison students. Among sexually active students at the 6-month follow-up, intervention students reported fewer sexual partners within the past 2 months, greater frequency of using condoms, and greater intentions to engage in sex less frequently and to use a condom when having sex. Intervention students were also more likely to believe that teens their age who engage in HIV risk behaviors are vulnerable to infection. The intervention neither delayed the onset nor decreased the frequency of sexual intercourse and the frequency of alcohol and other drug use before sex by the 6-month follow-up assessment.

CONCLUSIONS

The results suggest that skills-based risk reduction programs can have an effect on student behavior. Among sexually active students, evidence suggests that school-based interventions can reduce behavior associated with risk of HIV infection.

Comparison of HIV-risk behaviors and demographics of adolescents tested or not tested for HIV infection

In a survey of 2,548 adolescents, 11.5 percent reported ever having had the human immunodeficiency virus (HIV) antibody test. Those who had been tested were significantly more likely to be male, black, and to reside in metropolitan areas than those who had not been tested. Tested adolescents were more than three times as likely to report having injected drugs and were more than twice as likely to have had sexual intercourse, had sexual intercourse at earlier ages, and with multiple partners. More than half of adolescents who had been HIV-tested had no reported risks for HIV infection. More than one-quarter of adolescents not tested reported at least one HIV risk factor. These data suggest the importance of discussing the HIV testing and counseling process within any HIV education program directed to adolescents.

Health risks and health insurance claims costs. Results for health hazard appraisal responders and nonresponders

The health risks, health perceptions, and health claim costs of health hazard appraisal (HHA) responders and nonresponders were compared in a sample of employees of the Adolph Coors brewery. HHA responders had lower levels of risks than nonresponders. Responders also rated themselves in better health than nonresponders. Despite the health advantage, HHA responders were more likely to file health claims in 1989 than nonresponders and also had significantly greater claims costs. Comparing the top 10% most expensive employees in each group, however, nonresponders had greater claims costs than responders. Distribution patterns also differed based on perceived health status. HHA responders who perceived themselves in poor/fair health status tended to cost less than nonresponders of similar health. Responders perceiving themselves in good/excellent health status cost more than nonresponders. The findings support the "worried well" syndrome in healthy HHA responders.

LIFECHECK: a successful, low touch, low tech, in-plant, cardiovascular disease risk identification and modification program

LIFECHECK, a voluntary, in-plant cardiovascular risk identification and modification program, was developed to complement Coors Wellness Center-based programs. LIFECHECK was offered to the 1,320 employees located at the Coors Engineering Center and Can Manufacturing Complex at the Coors Brewing Company. The initial 30-minute screening included height, weight, blood pressure, cholesterol, smoking history, weekly Kcal expenditure, self-rating of health, and health effects of stress. Participants concluded the screening session with a wellness counselor who reviewed results and referred them to the appropriate intervention activities. The eight-week intervention was provided at the worksite and was available to all shifts. The intervention included an activity competition and activity classes; nutrition, hypertension, smoking, and lipid classes; a smoke-out day; one-on-one counseling; exercise equipment at four worksites; posters; traymats; table tents; and electronic messages. A total of 692 employees, 52% of those eligible, participated in the initial screening. Of these, 91% had one or more risk factors, and 33% had three to five cardiovascular disease risk factors. A total of 499 employees, 72% of those eligible, completed the follow-up screening. Thirty-two percent of the employees who participated in LIFECHECK had not used the Wellness Center in the eight years it had been open. There were significant changes in employees who completed the eight-week program for systolic blood pressure, total cholesterol, weight, physical activity, and risk of ischemic heart disease within eight years as measured by the Framingham score (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The risk of nursing home admission in three communities

Beginning in 1982, the 3-year incidence of nursing home admission was determined for community-dwelling residents aged 65 and over in East Boston, Massachusetts (4%); New Haven, Connecticut (9%); and Iowa and Washington Counties, Iowa (12%). A common methodology was used to collect baseline risk factor and follow-up data on nursing home admissions among persons in each community as part of the National Institute on Aging's Established Populations for Epidemiologic Studies of the Elderly. A multivariate logistic regression model of baseline risk factors that included the participant's age, race, sex, history of prior admission, ADL limitations, cognitive function, living arrangements, and level of income predicted 80% of the users in each community.

Total cerebral ischemia: application of a new model system to studies of cerebral microcirculation

Reduction in cerebral blood flow (CBF) following global ischemia has been implicated as a pathogenetic mechanism in progressive brain damage seen after restoration of effective cardiac action and cerebral perfusion pressure. There are serious limitations to many of the techniques for measuring regional cerebral blood flow, particularly during low flow states. In 15 dogs anesthetized with thiopental, 12 minutes of total cerebral ischemia (TCI) was produced using a double balloon occlusion technique. Total and regional cerebral blood flows were sequentially measured before and after balloon release by left ventricular injection of 15 mu microspheres labelled with 5 different radionuclides. Total CBF was reduced 53 +/- 5% (mean +/- SEM) from pre-ischemic values between 1 and 3 hours after "resuscitation" despite normal perfusion pressure and arterial blood gases. CBF remained slightly reduced (24 +/- 7%) at 6 hours post-ischemia. Thirty minutes after balloon release, grey matter flow was reduced 38 +/- 8% from control values while adjacent white matter flow was increased 21 +/- 10%. However, by 1 hour after ischemia, grey and white matter flows were both reduced (60 +/- 3%, 41 +/- 5% respectively). Similar differences in brain stem and cerebellar flow were also observed. The majority (71-86%) of the reduction in total CBF seen at one hour post-TCI is due to increased cerebrovascular resistance, with 14-29% of the decrease related to arteriovenous shunting.