1
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Loomer L. Worse quality at for-profit assisted living facilities in non-urban Minnesota. J Am Geriatr Soc 2024; 72:624-626. [PMID: 37909323 DOI: 10.1111/jgs.18657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/01/2023] [Indexed: 11/03/2023]
Affiliation(s)
- Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business and Economics, University of Minnesota Duluth, Duluth, Minnesota, USA
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2
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Loomer L. A Cross-Sectional Study of Nurse Turnover in Residential Care Communities. J Appl Gerontol 2024:7334648241230634. [PMID: 38298136 DOI: 10.1177/07334648241230634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
We examine what facility characteristics are associated with nurse turnover in residential care communities (RCCs). This is a cross-sectional study using the 2018 National Study of Long-term Care Provider Public Use File. There were 3331 RCCs (unweighted n = 272) represented when examining registered nurse (RN) turnover and when examining aide turnover there was a weighted sample of 13,676 RCCs (unweighted n = 68). RN turnover was 72% (95% confidence interval (CI) 59%, 84%), 52% reported 100% turnover. Aide turnover was 48% (95% CI 43%, 53%); 11% reported 100% turnover. We examined ownership and facility type, job design, economic, and working environment factors related to turnover. Using multivariate linear regression, non-profit RCCs had 25 percentage points lower RN turnover (95% CI: -44.46, -4.31) and 9.7 percentage points lower aide turnover (95% CI: 18.8, -0.6) compared to for-profits. We find larger RCCs had lower aide turnover.
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Affiliation(s)
- Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business and Economics, University of Minnesota Duluth, Duluth, MN, USA
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3
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Loomer L, Dauner KN, Schultz J. Association of Pay-for-Performance Reimbursement With Clinical Quality for Minnesota Nursing Homes Residents. Med Care Res Rev 2023; 80:484-495. [PMID: 37183707 DOI: 10.1177/10775587231170064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
In 2016, Minnesota implemented a new pay-for-performance reimbursement scheme for Medicaid residents in nursing homes, known as Value-Based Reimbursement (VBR). This study seeks to understand whether there is an association between VBR and quality improvement. We use data from 2013 to 2019 including Centers for Medicare and Medicaid Services, Nursing Home Compare, and Long-term care Facts in the US. Using multivariate regression with commuting zone fixed effects, we compare five long-stay and two short-stay clinical quality metrics in Minnesota nursing homes to nursing homes bordering states, before and after VBR was implemented. We find minimal significant changes in quality in Minnesota nursing homes after VBR. Minnesota should reconsider its pay-for-performance efforts.
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4
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Loomer L, Rahman M, Mroz TM, Gozalo PL, Mor V. Impact of higher payments for rural home health episodes on rehospitalizations. J Rural Health 2022. [PMID: 36336461 PMCID: PMC10163169 DOI: 10.1111/jrh.12725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE Home health agencies delivering care in rural counties face unique challenges when providing care to older adults; long travel times between each visit can limit the number of patients seen each day. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries without evaluating the policy's impact on patient outcomes. METHODS Using 100% Medicare data on postacute HH episodes from 2007 to 2014, we estimated the impact of higher payments on beneficiaries outcomes using difference-in-differences analysis, comparing rehospitalizations between rural and urban postacute HH episodes before and after 2010. FINDINGS Our sample included 5.6 million postacute HH episodes (18% rural). In the preperiod, the 30- and 60-day rehospitalization rates for urban HH episodes were 11.30% and 18.23% compared to 11.38% and 18.39% for rural HH episodes. After 2010, 30- and 60-day rehospitalization rates declined, 10.08% and 16.49% for urban HH episodes and 9.87% and 16.08% for rural HH episodes, respectively. The difference-in-difference estimate was 0.29 percentage points (P = .005) and 0.57 percentage points (P < .001) for 30- and 60-day rehospitalization, respectively. CONCLUSIONS Increasing payments resulted in a statistically significant reduction in rehospitalizations for rural postacute HH episodes. The add-on payment is set to sunset in 2022 and its impact on access and quality to HH for rural older adults should be reconsidered.
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Affiliation(s)
- Lacey Loomer
- Department of Economics and Health Care Management Labovitz School of Business and Management University of Minnesota Duluth Minnesota USA
| | - Momotazur Rahman
- Center for Gerontology and Healthcare Research School of Public Health Brown University Providence Rhode Island USA
| | - Tracy M. Mroz
- Department of Rehabilitation Medicine University of Washington Washington Seattle USA
| | - Pedro L. Gozalo
- Center for Gerontology and Healthcare Research School of Public Health Brown University Providence Rhode Island USA
- Providence VA Medical Center Providence Rhode Island USA
| | - Vincent Mor
- Department of Economics and Health Care Management Labovitz School of Business and Management University of Minnesota Duluth Minnesota USA
- Center for Gerontology and Healthcare Research School of Public Health Brown University Providence Rhode Island USA
- Providence VA Medical Center Providence Rhode Island USA
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5
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McCreedy EM, Yang X, Mitchell SL, Gutman R, Teno J, Loomer L, Moyo P, Volandes A, Gozalo PL, Belanger E, Ogarek J, Mor V. Effect of advance care planning video on do-not-hospitalize orders for nursing home residents with advanced illness. BMC Geriatr 2022; 22:298. [PMID: 35392827 PMCID: PMC8991654 DOI: 10.1186/s12877-022-02970-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of the study is to evaluate the effect of an Advance Care Planning (ACP) Video Program on documented Do-Not-Hospitalize (DNH) orders among nursing home (NH) residents with advanced illness. METHODS Secondary analysis on a subset of NHs enrolled in a cluster-randomized controlled trial (41 NHs in treatment arm implemented the ACP Video Program: 69 NHs in control arm employed usual ACP practices). Participants included long (> 100 days) and short (≤ 100 days) stay residents with advanced illness (advanced dementia or cardiopulmonary disease (chronic obstructive pulmonary disease or congestive heart failure)) in NHs from March 1, 2016 to May 31, 2018 without a documented Do-Not-Hospitalize (DNH) order at baseline. Logistic regression with covariate adjustments was used to estimate the impact of the resident being in a treatment versus control NH on: the proportion of residents with new DNH orders during follow-up; and the proportion of residents with any hospitalization during follow-up. Clustering at the facility-level was addressed using hierarchical models. RESULTS The cohort included 6,117 residents with advanced illness (mean age (SD) = 82.8 (8.4) years, 65% female). Among long-stay residents (n = 3,902), 9.3% (SE, 2.2; 95% CI 5.0-13.6) and 4.2% (SE, 1.1; 95% CI 2.1-6.3) acquired a new DNH order in the treatment and control arms, respectively (average marginal effect, (AME) 5.0; SE, 2.4; 95% CI, 0.3-9.8). Among short-stay residents with advanced illness (n = 2,215), 8.0% (SE, 1.6; 95% CI 4.6-11.3) and 3.5% (SE 1.0; 95% CI 1.5-5.5) acquired a new DNH order in the treatment and control arms, respectively (AME 4.4; SE, 2.0; 95% CI, 0.5-8.3). Proportion of residents with any hospitalizations did not differ between arms in either cohort. CONCLUSIONS Compared to usual care, an ACP Video Program intervention increased documented DNH orders among NH residents with advanced disease but did not significantly reduce hospitalizations. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02612688 .
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Affiliation(s)
- Ellen M McCreedy
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA. .,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.
| | - Xiaofei Yang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St, Boston, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Joan Teno
- Oregon Health Sciences University School of Medicine, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business and Economics, University of Minnesota Duluth, 1518 Kirby Dr, Duluth, MN, 55806, USA
| | - Patience Moyo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Angelo Volandes
- Section of General Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Emmanuelle Belanger
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Jessica Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
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Moyo P, Loomer L, Teno J, Gutman R, McCreedy EM, Bélanger E, Volandes AE, Mitchell S, Mor V. Effect of a Video-Assisted Advance Care Planning Intervention on End-of-Life Health Care Transitions Among Long-Stay Nursing Home Residents. J Am Med Dir Assoc 2022; 23:394-398. [PMID: 34627753 PMCID: PMC8885779 DOI: 10.1016/j.jamda.2021.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the relationship between an advance care planning (ACP) video intervention, Pragmatic Trial of Video Education in Nursing Homes (PROVEN), and end-of-life health care transitions among long-stay nursing home residents with advanced illness. DESIGN Pragmatic cluster randomized clinical trial. Five ACP videos were available on tablets or online at intervention facilities. PROVEN champions employed by nursing homes (usually social workers) were directed to offer residents (or their proxies) ≥1 video under certain circumstances. Control facilities employed usual ACP practices. SETTING AND PARTICIPANTS PROVEN occurred from February 2016 to May 2019 in 360 nursing homes (119 intervention, 241 control) owned by 2 health care systems. This post hoc study of PROVEN data analyzed long-stay residents ≥65 years who died during the trial who had either advanced dementia or cardiopulmonary disease (advanced illness). We required an observation time ≥90 days before death. The analytic sample included 923 and 1925 advanced illness decedents in intervention and control arms; respectively. METHODS Outcomes included the proportion of residents with 1 or more hospital transfer (ie, hospitalization, emergency department use, or observation stay), multiple (≥3) hospital transfers during the last 90 days of life, and late transitions (ie, hospital transfer during the last 3 days or hospice admission on the last day of life). RESULTS Hospital transfers in the last 90 days of life among decedents with advanced illness were significantly lower in the intervention vs control arm (proportion difference = -1.7%, 95% CI -3.2%, -0.1%). The proportion of decedents with multiple hospital transfers and late transitions did not differ between the trial arms. CONCLUSIONS AND IMPLICATIONS Video-assisted ACP was modestly associated with reduced hospital transfers in the last 90 days of life among nursing home residents with advanced illness. The intervention was not significantly associated with late health care transitions and multiple hospital transfers.
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Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Lacey Loomer
- University of Minnesota Duluth Labovitz School of Business
and Economics, Department of Economics and Health Care Management, Duluth, MN,
USA
| | - Joan Teno
- Oregon Health Sciences University School of Medicine,
Portland, OR, USA
| | - Roee Gutman
- Brown University School of Public Health, Department of
Biostatistics, Providence, RI, USA
| | - Ellen M. McCreedy
- Brown University School of Public Health, Department of
Health Services, Policy, and Practice, Providence, RI, USA
| | - Emmanuelle Bélanger
- Brown University School of Public Health, Department of
Health Services, Policy, and Practice, Providence, RI, USA
| | - Angelo E. Volandes
- General Medicine, Harvard Medical School, Boston, MA,
USA,Section of General Medicine, Massachusetts General
Hospital, Boston, MA
| | - Susan Mitchell
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for
Aging Research, Boston, MA, USA,Department of Medicine, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - Vincent Mor
- Brown University School of Public Health, Department of
Health Services, Policy, and Practice, Providence, RI, USA,Providence VA Medical Center, Long Term Services and
Supports Center of Innovation, Providence, RI, USA
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Loomer L, Grabowski DC, Yu H, Gandhi A. Association between nursing home staff turnover and infection control citations. Health Serv Res 2021; 57:322-332. [PMID: 34490625 DOI: 10.1111/1475-6773.13877] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 08/20/2021] [Accepted: 08/29/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To describe the association between nursing home staff turnover and the presence and scope of infection control citations. DATA SOURCES Secondary data for all US nursing homes between March 31, 2017, through December 31, 2019 were obtained from Payroll-Based Journal (PBJ), Nursing Home Compare, and Long-Term Care: Facts on Care in the US (LTC Focus). STUDY DESIGN We estimated the association between nurse turnover and the probability of an infection control citation and the scope of the citation while controlling for nursing home fixed effects. Our turnover measure is the percent of the facility's nursing staff hours that were provided by new staff (less than 60 days of experience in the last 180 days) during the 2 weeks prior to the health inspection. We calculated turnover for all staff together and separately for registered nurses, licensed practical nurses (LPNs), and certified nursing assistants. DATA COLLECTION/EXTRACTION METHODS We linked nursing homes standard inspection surveys to 650 million shifts from the PBJ data. We excluded any nursing home with incomplete or missing staffing data. Our final analytic sample included 12,550 nursing homes with 30,536 surveys. PRINCIPAL FINDINGS Staff turnover was associated with an increased likelihood of an infection control citation (average marginal effect [AME] = 0.12 percentage points [pp]; 95% confidence interval [CI]: 0.05, 0.18). LPN (AME = 0.06 pp; 95% CI: 0.01, 0.11) turnover was conditionally associated with an infection control citation. Conditional on having at least an isolated citation for infection control, staff turnover was positively associated with receiving a citation coded as a "pattern" (AME = 0.21 pp; 95% CI: 0.10, 0.32). Conditional of having at least a pattern citation, staff turnover was positively associated with receiving a widespread citation (AME = 0.21 pp; 95% CI: 0.10, 0.32). CONCLUSIONS Turnover was positively associated with the probability of an infection control citation. Staff turnover should be considered an important factor related to the spread of infections within nursing homes.
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Affiliation(s)
- Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business and Economics, University of Minnesota Duluth, Duluth, Minnesota, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Huizi Yu
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ashvin Gandhi
- UCLA Anderson School of Management, Los Angeles, California, USA
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Shen K, Loomer L, Abrams H, Grabowski DC, Gandhi A. Estimates of COVID-19 Cases and Deaths Among Nursing Home Residents Not Reported in Federal Data. JAMA Netw Open 2021; 4:e2122885. [PMID: 34499136 PMCID: PMC8430452 DOI: 10.1001/jamanetworkopen.2021.22885] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/24/2021] [Indexed: 02/04/2023] Open
Abstract
Importance Federal data underestimate the impact of COVID-19 on US nursing homes because federal reporting guidelines did not require facilities to report case and death data until the week ending May 24, 2020. Objective To assess the magnitude of unreported cases and deaths in the National Healthcare Safety Network (NHSN) and provide national estimates of cases and deaths adjusted for nonreporting. Design, Setting, and Participants This is a cross-sectional study comparing COVID-19 cases and deaths reported by US nursing homes to the NHSN with those reported to state departments of health in late May 2020. The sample includes nursing homes from 20 states, with 4598 facilities in 12 states that required facilities to report cases and 7401 facilities in 19 states that required facilities to report deaths. Estimates of nonreporting were extrapolated to infer the national (15 397 facilities) unreported cases and deaths in both May and December 2020. Data were analyzed from December 2020 to May 2021. Exposures Nursing home ownership (for-profit or not-for-profit), chain affiliation, size, Centers for Medicare & Medicaid Services star rating, and state. Main Outcomes and Measures The main outcome was the difference between the COVID-19 cases and deaths reported by each facility to their state department of health vs those reported to the NHSN. Results Among 15 415 US nursing homes, including 4599 with state case data and 7405 with state death data, a mean (SE) of 43.7% (1.4%) of COVID-19 cases and 40.0% (1.1%) of COVID-19 deaths prior to May 24 were not reported in the first NHSN submission in sample states, suggesting that 68 613 cases and 16 623 deaths were omitted nationwide, representing 11.6% of COVID-19 cases and 14.0% of COVID-19 deaths among nursing home residents in 2020. Conclusions and Relevance These findings suggest that federal NHSN data understated total cases and deaths in nursing homes. Failure to account for this issue may lead to misleading conclusions about the role of different facility characteristics and state or federal policies in explaining COVID outbreaks.
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Affiliation(s)
- Karen Shen
- Department of Economics, Harvard University, Cambridge, Massachusetts
| | - Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business and Economics, University of Minnesota, Duluth
| | - Hannah Abrams
- Department of Medicine, Massachusetts General Hospital, Boston
| | - David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ashvin Gandhi
- Anderson School of Management, University of California, Los Angeles
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Dauner KN, Loomer L. A qualitative assessment of barriers and facilitators associated with addressing social determinants of health among members of a health collaborative in the rural Midwest. BMC Health Serv Res 2021; 21:867. [PMID: 34429097 PMCID: PMC8384464 DOI: 10.1186/s12913-021-06859-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/30/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose Rural communities have unique economic and social structures, different disease burdens, and a more patchworked healthcare delivery system compared to urban counterparts. Yet research into addressing social determinants of health has focused on larger, urban, integrated health systems. Our study sought to understand capacities, facilitators, and barriers related to addressing social health needs across a collaborative of independent provider organizations in rural Northeastern Minnesota and Northwestern Wisconsin. Methods We conducted qualitative, semi-structured interviews with a purposive sample of 37 key informants from collaborative members including 4 stand-alone critical access hospitals, 3 critical access hospitals affiliated with primary care, 1 multi-clinic system, and 1 integrated regional health system. Findings Barriers were abundant and occurred at the organizational, community and policy levels. Rural providers described a lack of financial, labor, Internet, and community-based social services resources, a limited capacity to partner with other organizations, and workflows that were less than optimal for addressing SDOH. State Medicaid and other payer policies posed challenges that made it more difficult to use available resources, as did misaligned incentives between partners. While specific payer programs and organizational innovations helped facilitate their work, nothing was systemic. Relationships within the collaborative that allowed sharing of innovations and information were helpful, as was the role leadership played in promoting value-based care. Conclusions Policy change is needed to support rural providers in this work. Collaboration among rural health systems should be fostered to develop common protocols, promote value-based care, and offer economies of scale to leverage value-based payment. States can help align incentives and performance metrics across rural health care entities, engage payers in promoting value-based care, and bolster social service capacity.
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Affiliation(s)
- Kim Nichols Dauner
- Department of Economics and Health Care Management, Labovitz School of Business & Economics, University of Minnesota Duluth, 1318 Kirby Drive, Duluth, MN, 55812, USA.
| | - Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business & Economics, University of Minnesota Duluth, 1318 Kirby Drive, Duluth, MN, 55812, USA
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10
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Loomer L, Ogarek JA, Mitchell SL, Volandes AE, Gutman R, Gozalo PL, McCreedy EM, Mor V. Impact of an Advance Care Planning Video Intervention on Care of Short-Stay Nursing Home Patients. J Am Geriatr Soc 2020; 69:735-743. [PMID: 33159697 DOI: 10.1111/jgs.16918] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES To assess whether an advance care planning (ACP) video intervention impacts care among short-stay nursing home (NH) patients. DESIGN PRagmatic trial of Video Education in Nursing Homes (PROVEN) was a pragmatic cluster randomized clinical trial. SETTING A total of 360 NHs (N = 119 intervention, N = 241 control) owned by two healthcare systems. PARTICIPANTS A total of 2,538 and 5,290 short-stay patients with advanced dementia or cardiopulmonary disease (advanced illness) in the intervention and control arms, respectively; 23,302 and 50,815 short-stay patients without advanced illness in the intervention and control arms, respectively. INTERVENTION Five ACP videos were available on tablets or online. Designated champions at each intervention facility were instructed to offer a video to patients (or proxies) on admission. Control facilities used usual ACP practices. MEASUREMENTS Follow-up time was at most 100 days for each patient. Outcomes included hospital transfers per 1000 person-days alive and the proportion of patients experiencing more than one hospital transfer, more than one burdensome treatment (tube-feeding, parenteral therapy, invasive mechanical intervention, and intensive care unit admission), and hospice enrollment. Champions recorded whether a video was offered in the patients' electronic medical record. RESULTS There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention versus control groups with advanced illness (rate (95% confidence interval (CI)), 12.3 (11.6-13.1) vs 13.2 (12.5-13.7); rate difference: -0.8; 95% CI = -1.8-0.2)). There was a nonsignificant reduction in hospital transfers per 1000 person-days alive in the intervention versus control among short-stay patients without advanced illness. Secondary outcomes did not differ between groups among patients with and without advanced illness. Based on champion only reports 14.2% and 15.3% of eligible short-stay patients with and without advanced illness were shown videos, respectively. CONCLUSION An ACP video program did not significantly reduce hospital transfers, burdensome treatment, or hospice enrollment among short-stay NH patients; however, fidelity to the intervention was low.
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Affiliation(s)
- Lacey Loomer
- Department of Economics, Labovitz School of Business and Economics, Duluth, Minnesota, USA
| | - Jessica A Ogarek
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Susan L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Angelo E Volandes
- General Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Section of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Pedro L Gozalo
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
| | - Ellen M McCreedy
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Vincent Mor
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
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11
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Kosar CM, Loomer L, Thomas KS, White EM, Panagiotou OA, Rahman M. Association of Diagnosis Coding With Differences in Risk-Adjusted Short-term Mortality Between Critical Access and Non-Critical Access Hospitals. JAMA 2020; 324:481-487. [PMID: 32749490 PMCID: PMC7403917 DOI: 10.1001/jama.2020.9935] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
IMPORTANCE Critical access hospitals (CAHs) provide care to rural communities. Increasing mortality rates have been reported for CAHs relative to non-CAHs. Because Medicare reimburses CAHs at cost, CAHs may report fewer diagnoses than non-CAHs, which may affect risk-adjusted comparisons of outcomes. OBJECTIVE To assess serial differences in risk-adjusted mortality rates between CAHs and non-CAHs after accounting for differences in diagnosis coding. DESIGN, SETTING, AND PARTICIPANTS Serial cross-sectional study of rural Medicare Fee-for-Service beneficiaries admitted to US CAHs and non-CAHs for pneumonia, heart failure, chronic obstructive pulmonary disease, arrhythmia, urinary tract infection, septicemia, and stroke from 2007 to 2017. The final date of follow-up was December 31, 2017. EXPOSURE Admission to a CAH vs non-CAH. MAIN OUTCOMES AND MEASURES Discharge diagnosis count including trends from 2010 to 2011 when Medicare expanded the allowable number of billing codes for hospitalizations, and combined in-hospital and 30-day postdischarge mortality adjusted for demographics, primary diagnosis, preexisting conditions, and with vs without further adjustment for Hierarchical Condition Category (HCC) score to understand the contribution of in-hospital secondary diagnoses. RESULTS There were 4 094 720 hospitalizations (17% CAH) for 2 850 194 unique Medicare beneficiaries (mean [SD] age, 76.3 [11.7] years; 55.5% women). Patients in CAHs were older (median age, 80.1 vs 76.8 years) and more likely to be female (58% vs 55%). In 2010, the adjusted mean discharge diagnosis count was 7.52 for CAHs vs 8.53 for non-CAHs (difference, -0.99 [95% CI, -1.08 to -0.90]; P < .001). In 2011, the CAH vs non-CAH difference in diagnoses coded increased (P < .001 for interaction between CAH and year) to 9.27 vs 12.23 (difference, -2.96 [95% CI, -3.19 to -2.73]; P < .001). Adjusted mortality rates from the model with HCC were 13.52% for CAHs vs 11.44% for non-CAHs (percentage point difference, 2.08 [95% CI, 1.74 to 2.42]; P < .001) in 2007 and increased to 15.97% vs 12.46% (difference, 3.52 [95% CI, 3.09 to 3.94]; P < .001) in 2017 (P < .001 for interaction). Adjusted mortality rates from the model without HCC were not significantly different between CAHs and non-CAHs in all years except 2007 (12.19% vs 11.74%; difference, 0.45 [95% CI, 0.12 to 0.79]; P = .008) and 2010 (12.71% vs 12.28%; difference, 0.42 [95% CI, 0.07 to 0.77]; P = .02). CONCLUSIONS AND RELEVANCE For rural Medicare beneficiaries hospitalized from 2007 to 2017, CAHs submitted significantly fewer hospital diagnosis codes than non-CAHs, and short-term mortality rates adjusted for preexisting conditions but not in-hospital comorbidity measures were not significantly different by hospital type in most years. The findings suggest that short-term mortality outcomes at CAHs may not differ from those of non-CAHs after accounting for different coding practices for in-hospital comorbidities.
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Affiliation(s)
- Cyrus M. Kosar
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Kali S. Thomas
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
- Department of Veteran Affairs Medical Center, Providence, Rhode Island
| | - Elizabeth M. White
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Orestis A. Panagiotou
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
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12
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Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, McCreedy EM, Zhai R, Mor V. Advance Care Planning Video Intervention Among Long-Stay Nursing Home Residents: A Pragmatic Cluster Randomized Clinical Trial. JAMA Intern Med 2020; 180:1070-1078. [PMID: 32628258 PMCID: PMC7399750 DOI: 10.1001/jamainternmed.2020.2366] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Standardized, evidenced-based approaches to conducting advance care planning (ACP) in nursing homes are lacking. OBJECTIVE To test the effect of an ACP video program on hospital transfers, burdensome treatments, and hospice enrollment among long-stay nursing home residents with and without advanced illness. DESIGN, SETTING, AND PARTICIPANTS The Pragmatic Trial of Video Education in Nursing Homes was a pragmatic cluster randomized clinical trial conducted between February 1, 2016, and May 31, 2019, at 360 nursing homes (119 intervention and 241 control) in 32 states owned by 2 for-profit corporations. Participants included 4171 long-stay residents with advanced dementia or cardiopulmonary disease (hereafter referred to as advanced illness) in the intervention group and 8308 long-stay residents with advanced illness in the control group, 5764 long-stay residents without advanced illness in the intervention group, and 11 773 long-stay residents without advanced illness in the control group. Analyses followed the intention-to-treat principle. INTERVENTIONS Five 6- to 10-minute ACP videos were made available on tablet computers or online. Designated champions (mostly social workers) in intervention facilities were instructed to offer residents (or their proxies) the opportunity to view a video(s) on admission and every 6 months. Control facilities used usual ACP practices. MAIN OUTCOMES AND MEASURES Twelve-month outcomes were measured for each resident. The primary outcome was hospital transfers per 1000 person-days alive in the advanced illness cohort. Secondary outcomes included the proportion of residents with or without advanced illness experiencing 1 or more hospital transfer, 1 or more burdensome treatment, and hospice enrollment. To monitor fidelity, champions completed reports in the electronic record whenever they offered to show residents a video. RESULTS The study included 4171 long-stay residents with advanced illness in the intervention group (2970 women [71.2%]; mean [SD] age, 83.6 [9.1] years), and 8308 long-stay residents with advanced illness in the control group (5857 women [70.5%]; mean [SD] age, 83.6 [8.9] years), 5764 long-stay residents without advanced illness in the intervention group (3692 women [64.1%]; mean [SD] age, 81.5 [9.2] years), and 11 773 long-stay residents without advanced illness in the control group (7467 women [63.4%]; mean [SD] age, 81.3 [9.2] years). There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention vs control groups (rate [SE], 3.7 [0.2]; 95% CI, 3.4-4.0 vs 3.9 [0.3]; 95% CI, 3.6-4.1; rate difference [SE], -0.2 [0.3]; 95% CI, -0.5 to 0.2). Secondary outcomes did not significantly differ between trial groups among residents with and without advanced illness. Based on champions' reports, 912 of 4171 residents with advanced illness (21.9%) viewed ACP videos. Facility-level rates of showing ACP videos ranged from 0% (14 of 119 facilities [11.8%]) to more than 40% (22 facilities [18.5%]). CONCLUSIONS AND RELEVANCE This study found that an ACP video program was not effective in reducing hospital transfers, decreasing burdensome treatment use, or increasing hospice enrollment among long-stay residents with or without advanced illness. Intervention fidelity was low, highlighting the challenges of implementing new programs in nursing homes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02612688.
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Affiliation(s)
- Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Angelo E Volandes
- Section of General Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Lacey Loomer
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ellen M McCreedy
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ruoshui Zhai
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Affairs Medical Center, Providence, Rhode Island
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13
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Abrams HR, Loomer L, Gandhi A, Grabowski DC. Characteristics of U.S. Nursing Homes with COVID-19 Cases. J Am Geriatr Soc 2020; 68:1653-1656. [PMID: 32484912 PMCID: PMC7300642 DOI: 10.1111/jgs.16661] [Citation(s) in RCA: 239] [Impact Index Per Article: 59.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 05/27/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES The 2019 coronavirus disease (COVID‐19) has been documented in a large share of nursing homes throughout the United States, leading to high rates of mortality for residents. To understand how to prevent and mitigate future outbreaks, it is imperative that we understand which nursing homes are more likely to experience COVID‐19 cases. Our aim was to examine the characteristics of nursing homes with documented COVID‐19 cases in the 30 states reporting the individual facilities affected. DESIGN We constructed a database of nursing homes with verified COVID‐19 cases as of May 11, 2020, via correspondence with and publicly available reports from state departments of health. We linked this information to nursing home characteristics and used regression analysis to examine the association between these characteristics and the likelihood of having a documented COVID‐19 case. SETTING All nursing homes from 30 states that reported COVID‐19 cases at the facility‐level. PARTICIPANTS Nursing home residents in states reporting data. MEASUREMENTS Whether a nursing home had a reported COVID‐19 case (yes/no), and conditional on having a case, the number of cases at a nursing home. RESULTS Of 9,395 nursing homes in our sample, 2,949 (31.4%) had a documented COVID‐19 case. Larger facility size, urban location, greater percentage of African American residents, non‐chain status, and state were significantly (P < .05) related to the increased probability of having a COVID‐19 case. Five‐star rating, prior infection violation, Medicaid dependency, and ownership were not significantly related. CONCLUSION COVID‐19 cases in nursing homes are related to facility location and size and not traditional quality metrics such as star rating and prior infection control citations. J Am Geriatr Soc 68:1653‐1656, 2020.
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Loomer L, Rahman M, Mroz TM, Gozalo PL, Mor V. Do Higher Payments Increase Access to Post-Acute Home Health Care for Rural Medicare Beneficiaries? J Am Geriatr Soc 2020; 68:663-664. [PMID: 31981363 DOI: 10.1111/jgs.16332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/21/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Lacey Loomer
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Momotazur Rahman
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
| | - Tracy M Mroz
- Division of Occupational Therapy, Department of Rehabilitation Medicine, Washington, University of Washington, Seattle
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island.,Providence VA Medical Center, Providence, Rhode Island
| | - Vincent Mor
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island.,Providence VA Medical Center, Providence, Rhode Island
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Abstract
IMPORTANCE Although people living in rural areas of the United States are disproportionately older and more likely to die of conditions that require postacute care than those living in urban areas, rural-urban differences in postacute care utilization and outcomes have been understudied. OBJECTIVE To describe rural-urban differences in postacute care utilization and postdischarge outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from Medicare beneficiaries 66 years and older admitted to 4738 US acute care hospitals for stroke, hip fracture, chronic obstructive pulmonary disease, congestive heart failure, or pneumonia between January 1, 2011, and September 30, 2015. Participants were tracked for 180 days after discharge. Data analyses were conducted between October 1, 2018, and May 30, 2019. EXPOSURES County of residence was classified as urban or rural using the US Department of Agriculture Rural-Urban Continuum Codes. Rural counties were divided into those adjacent and not adjacent to urban counties. MAIN OUTCOMES AND MEASURES Primary outcomes were discharge to community vs a formal postacute care setting (ie, skilled nursing facility, home health care, or inpatient rehabilitation facility) and readmission and mortality within 30, 90, and 180 days of hospital discharge. RESULTS Among 2 044 231 hospitalizations from 2011 to 2015, 1 538 888 (75.2%; mean [SD] age, 80.4 [8.3] years; 866 540 [56.3%] women) were among patients from urban counties, 322 360 (15.8%; mean [SD] age, 79.6 [8.1] years; 175 806 [54.5%] women) were among patients from urban-adjacent rural counties, and 182 983 (9.0%; mean [SD] age, 79.8 [8.1] years; 98 775 [54.0%] women) were among patients from urban-nonadjacent rural counties. The probability of discharge to community without postacute care did not differ by rurality. However, compared with patients from urban counties, patients from the most rural counties were more frequently discharged to a skilled nursing facility (adjusted difference, 3.5 [95% CI, 2.8-4.3] percentage points), while discharge to an inpatient rehabilitation facility was less common among patients from rural counties than among those from urban counties (urban vs urban-adjacent rural: adjusted difference, -1.9 [95% CI, -2.4 to -1.4] percentage points; urban vs urban-nonadjacent rural: adjusted difference, -1.8 [95% CI, -2.4 to -1.2] percentage points) as was discharge to home health care (urban vs urban-adjacent rural: adjusted difference, -1.7 [95% CI, -2.3 to -1.2] percentage points; urban vs urban-nonadjacent rural: adjusted difference, -2.4 [95% CI, -3.0 to -1.8]). For patients from the most rural counties, adjusted 30-day readmission rates were 0.4 (95% CI, 0.2-0.6) percentage points higher than those of patients from urban counties among those who were discharged to the community but 0.3 (95% CI, -0.6 to -0.1) percentage points lower among patients receiving postacute care. Adjusted 30-day mortality rates were 0.4 (95% CI, 0.3-0.5) percentage points higher for patients from the most rural counties discharged to the community and 2.0 (95% CI, -1.7 to 2.3) percentage points higher among those receiving postacute care. Rural-urban differences in 90-day and 180-day outcomes were similar. CONCLUSIONS AND RELEVANCE These findings suggest that rates of discharge to the community and postacute care settings were similar among patients from rural and urban counties. Rural-urban differences in mortality following discharge were much larger for patients receiving postacute care compared with patients discharged to the community setting. Improving postacute care in rural areas may reduce rural-urban disparities in patient outcomes.
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Affiliation(s)
- Cyrus M. Kosar
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Lacey Loomer
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Nasim B. Ferdows
- Edward R. Roybal Institute on Aging, University of Southern California, Los Angeles
| | - Amal N. Trivedi
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Orestis A. Panagiotou
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Momotazur Rahman
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
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17
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Palmer JA, Parker VA, Barre LR, Mor V, Volandes AE, Belanger E, Loomer L, McCreedy E, Mitchell SL. Understanding implementation fidelity in a pragmatic randomized clinical trial in the nursing home setting:a mixed-methods examination. Trials 2019. [PMID: 31779684 DOI: 10.1186/s13063‐019‐3725‐5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Pragmatic Trial of Video Education in Nursing Homes (PROVEN) is one of the first large pragmatic randomized clinical trials (pRCTs) to be conducted in U.S. nursing homes (N = 119 intervention and N = 241 control across two health-care systems). The trial aims to evaluate the effectiveness of a suite of videos to improve advance care planning (ACP) for nursing home patients. This report uses mixed methods to explore the optimal and suboptimal conditions necessary for implementation fidelity within pRCTs in nursing homes. METHODS PROVEN's protocol required designated facility champions to offer an ACP video to long-stay patients every 6 months during the 18-month implementation period. Champions completed a video status report, stored within electronic medical records, each time a video was offered. Data from the report were used to derive each facility's adherence rate (i.e., cumulative video offer). Qualitative interviews held after 15 months with champions were purposively sampled from facilities within the highest and lowest adherence rates (i.e., those in the top and bottom quintiles). Two researchers analyzed interview data thematically using a deductive approach based upon six domains of the revised Conceptual Framework for Implementation Fidelity (CFIF). Matrices were developed to compare coded narratives by domain across facility adherence status. RESULTS In total, 28 interviews involving 33 champions were analyzed. Different patterns were observed across high- versus low-adherence facilities for five CFIF domains. In low-adherence nursing homes, (1) there were limited implementation resources (Context), (2) there was often a perceived negative patient or family responsiveness to the program (Participant Responsiveness), and (3) champions were reticent in offering the videos (Recruitment). In high-adherence nursing homes, (1) there was more perceived patient and family willingness to engage in the program (Participant Responsiveness), (2) champions supplemented the video with ACP conversations (Quality of Delivery), (3) there were strategic approaches to recruitment (Recruitment), and (4) champions appreciated external facilitation (Strategies to Facilitate Implementation). CONCLUSIONS Critical lessons for implementing pRCTs in nursing homes emerged from this report: (1) flexible fidelity is important (i.e., delivering core elements of an intervention while permitting the adaptation of non-core elements), (2) reciprocal facilitation is vital (i.e., early and ongoing stakeholder engagement in research design and, reciprocally, researchers' and organizational leaders' ongoing support of the implementation), and (3) organizational and champion readiness should be formally assessed early and throughout implementation to facilitate remediation. TRIAL REGISTRATION ClinicalTrials.gov, NCT02612688. Registered on 19 November 2015.
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Affiliation(s)
- Jennifer A Palmer
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA. .,Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA. .,Department of Medicine, Beth Israel Deaconess Medical Center, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Victoria A Parker
- Peter T. Paul College of Business and Economics, University of New Hampshire, 10 Garrison Avenue, Durham, NH, 03824, USA
| | - Lacey R Barre
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Administration Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA
| | - Angelo E Volandes
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Section of General Medicine, Massachusetts General Hospital, 55 Fruit Street Gray 7-730, Boston, MA, 02114, USA
| | - Emmanuelle Belanger
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Susan L Mitchell
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA
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18
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Palmer JA, Parker VA, Barre LR, Mor V, Volandes AE, Belanger E, Loomer L, McCreedy E, Mitchell SL. Understanding implementation fidelity in a pragmatic randomized clinical trial in the nursing home setting:a mixed-methods examination. Trials 2019; 20:656. [PMID: 31779684 PMCID: PMC6883560 DOI: 10.1186/s13063-019-3725-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 09/13/2019] [Indexed: 11/26/2022] Open
Abstract
Background The Pragmatic Trial of Video Education in Nursing Homes (PROVEN) is one of the first large pragmatic randomized clinical trials (pRCTs) to be conducted in U.S. nursing homes (N = 119 intervention and N = 241 control across two health-care systems). The trial aims to evaluate the effectiveness of a suite of videos to improve advance care planning (ACP) for nursing home patients. This report uses mixed methods to explore the optimal and suboptimal conditions necessary for implementation fidelity within pRCTs in nursing homes. Methods PROVEN’s protocol required designated facility champions to offer an ACP video to long-stay patients every 6 months during the 18-month implementation period. Champions completed a video status report, stored within electronic medical records, each time a video was offered. Data from the report were used to derive each facility’s adherence rate (i.e., cumulative video offer). Qualitative interviews held after 15 months with champions were purposively sampled from facilities within the highest and lowest adherence rates (i.e., those in the top and bottom quintiles). Two researchers analyzed interview data thematically using a deductive approach based upon six domains of the revised Conceptual Framework for Implementation Fidelity (CFIF). Matrices were developed to compare coded narratives by domain across facility adherence status. Results In total, 28 interviews involving 33 champions were analyzed. Different patterns were observed across high- versus low-adherence facilities for five CFIF domains. In low-adherence nursing homes, (1) there were limited implementation resources (Context), (2) there was often a perceived negative patient or family responsiveness to the program (Participant Responsiveness), and (3) champions were reticent in offering the videos (Recruitment). In high-adherence nursing homes, (1) there was more perceived patient and family willingness to engage in the program (Participant Responsiveness), (2) champions supplemented the video with ACP conversations (Quality of Delivery), (3) there were strategic approaches to recruitment (Recruitment), and (4) champions appreciated external facilitation (Strategies to Facilitate Implementation). Conclusions Critical lessons for implementing pRCTs in nursing homes emerged from this report: (1) flexible fidelity is important (i.e., delivering core elements of an intervention while permitting the adaptation of non-core elements), (2) reciprocal facilitation is vital (i.e., early and ongoing stakeholder engagement in research design and, reciprocally, researchers’ and organizational leaders’ ongoing support of the implementation), and (3) organizational and champion readiness should be formally assessed early and throughout implementation to facilitate remediation. Trial registration ClinicalTrials.gov, NCT02612688. Registered on 19 November 2015.
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Affiliation(s)
- Jennifer A Palmer
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA. .,Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA. .,Department of Medicine, Beth Israel Deaconess Medical Center, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Victoria A Parker
- Peter T. Paul College of Business and Economics, University of New Hampshire, 10 Garrison Avenue, Durham, NH, 03824, USA
| | - Lacey R Barre
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Administration Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA
| | - Angelo E Volandes
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Section of General Medicine, Massachusetts General Hospital, 55 Fruit Street Gray 7-730, Boston, MA, 02114, USA
| | - Emmanuelle Belanger
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Susan L Mitchell
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA
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19
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Loomer L, Volandes AE, Mitchell SL, Belanger E, McCreedy E, Palmer JA, Mor V. Black Nursing Home Residents More Likely to Watch Advance Care Planning Video. J Am Geriatr Soc 2019; 68:603-608. [PMID: 31660609 DOI: 10.1111/jgs.16237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES This study aims to identify resident characteristics associated with being offered and subsequently shown an advance care planning (ACP) video in the Pragmatic Trial of Video Education in Nursing Homes (PROVEN) and if differences are driven by within- and/or between-facility differences. DESIGN Cross-sectional study, from March 1, 2016, to May 31, 2018. SETTING A total of 119 PROVEN intervention nursing homes (NHs). PARTICIPANTS A total of 43 303 new NH admissions. MEASUREMENTS Data came from the Minimum Data Set and an electronic record documenting whether a video was offered and shown to residents. We conduct both naïve logistic regression models and hierarchical logistic models, controlling for NH fixed effects, to examine the overall differences in offer and show rate by resident characteristics. RESULTS In naïve regression models, compared to white residents, black residents are 7.8 percentage point (pp) (95% confidence interval [CI] = -9.1 to -6.5 pp) less likely to be offered the video. These differences decrease to 1.3 pp (95% CI = -2.61 to -0.02 pp) when accounting for NH fixed effects. In fully adjusted models, black residents compared to white residents were 2.1 pp more likely to watch the video contingent on being offered (95% CI = 0.4-3.7 pp). Residents with cognitive impairment were less likely to be offered and shown the video. CONCLUSIONS After controlling for NH fixed effects, there were smaller racial differences in being offered the video, but once offered, black residents were more likely to watch the video. This suggests that black residents are receptive to this type of ACP intervention but need to be given an opportunity to be exposed. J Am Geriatr Soc 68:603-608, 2020.
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Affiliation(s)
- Lacey Loomer
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Angelo E Volandes
- Section of General Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Susan L Mitchell
- Hebrew Senior Life, Institute for Aging Research, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Emmanuelle Belanger
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
| | - Jennifer A Palmer
- Hebrew Senior Life, Institute for Aging Research, Boston, Massachusetts
| | - Vincent Mor
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island.,Providence Veterans Administration Medical Center, Center of Innovation in Health Services Research & Development Service (HSR&D), Providence, Rhode Island
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20
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Abstract
Nationwide nursing home private-pay prices at the facility-level have not been available for researchers interested in studying this unique health care market. This study presents a new data source, Caregiverlist, for private-pay prices for private and semiprivate rooms for 12,000 nursing homes nationwide collected between 2008 and 2010. We link these data to publicly available national nursing home-level data sets to examine the relationship between price and nursing home characteristics. We also compare private-pay prices with average private-pay revenues per day for California nursing homes obtained from facilities' financial filings. On average, private-pay prices were $224 per day for private rooms compared with $197 per day for semiprivate rooms. We find that nursing homes that are nonprofit, urban, hospital-based, have a special care unit, chain-owned, and have higher quality ratings have higher prices. We find average revenues per day in California to be moderately correlated with prices reported by Caregiverlist.
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Affiliation(s)
| | - Ashvin Gandhi
- University of California-Los Angeles, Los Angeles, CA, USA
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21
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Palmer JA, Parker VA, Mor V, Volandes AE, Barre LR, Belanger E, Carter P, Loomer L, McCreedy E, Mitchell SL. Barriers and facilitators to implementing a pragmatic trial to improve advance care planning in the nursing home setting. BMC Health Serv Res 2019; 19:527. [PMID: 31357993 PMCID: PMC6664774 DOI: 10.1186/s12913-019-4309-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/30/2019] [Indexed: 11/27/2022] Open
Abstract
Background The PRagmatic trial Of Video Education in Nursing homes (PROVEN) aims to test the effectiveness of an advance care planning (ACP) video intervention. Relatively little is known about the challenges associated with implementing ACP interventions in the nursing home (NH) setting, especially within a pragmatic trial. To address this research gap, this report sought to identify facilitators of and barriers to implementing PROVEN from the perspective of the Champions charged with introducing the ACP video program delivery to patients and families. Methods In semi-structured telephone interviews at 4 and 15 months of the 18-month implementation period, ACP Champions at all PROVEN intervention facilities (N = 119) were asked about their perceptions of program implementation. Forty interviews were purposively sampled, transcribed, and analyzed using a hybrid deductive/inductive approach to thematic analysis incorporating the Consolidated Framework for Implementation Research’s domains: Intervention Characteristics (IC), Inner Setting (IS), Characteristics of Individuals (CI), Outer Setting (OS), and Process (P). Results Implementation facilitators identified by Champions included: the intervention’s adaptable mode of presentation and minimal time burden (IC) as well as the program’s customizable delivery to patients and families and opportunity for group reflection on implementation among ACP Champions (P). Barriers included mandated protocol-driven aspects of the program (OS), limited time to deliver the intervention (IS), and lack of perceived relevance and emotional readiness for ACP amongst stakeholders (CI). Conclusions Despite the promise of PROVEN’s intervention for improving ACP in nursing homes, unchangeable setting and characteristics of Champions, patients, and family members presented implementation barriers. Researchers need to engage all program participants (i.e., facility staff, patients, and families), in addition to corporate-level stakeholders, in early pragmatic trial design to minimize such obstacles. Further, despite the facilitating nature of PROVEN’s implementation processes, the study encountered tension between scientific rigor and real-world demands. Researchers need to optimize the real-world authenticity of pragmatic trial design while avoiding excessive implementation protocol deviations. Trial registration ClinicalTrials.gov Identifier: NCT02612688. Registered 19 November 2015. Electronic supplementary material The online version of this article (10.1186/s12913-019-4309-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jennifer A Palmer
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA. .,Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA. .,Beth Israel Deaconess Medical Center, Department of Medicine, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Victoria A Parker
- Peter T. Paul College of Business and Economics, University of New Hampshire, 10 Garrison Avenue, Durham, NH, 03824, USA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA.,Providence Veterans Administration Medical Center, Center of Innovation in Health Services Research and Development Service, 830 Chalkstone Avenue, Providence, RI, 02908, USA
| | - Angelo E Volandes
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Massachusetts General Hospital, Section of General Medicine, 55 Fruit Street Gray 7-730, Boston, MA, 02114, USA
| | - Lacey R Barre
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA
| | - Emmanuelle Belanger
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA
| | - Phoebe Carter
- Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA
| | - Susan L Mitchell
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA.,Beth Israel Deaconess Medical Center, Department of Medicine, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA
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22
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Loomer L, McCreedy E, Belanger E, Palmer JA, Mitchell SL, Volandes AE, Mor V. Nursing Home Characteristics Associated With Implementation of an Advance Care Planning Video Intervention. J Am Med Dir Assoc 2019; 20:804-809.e1. [PMID: 30852167 PMCID: PMC6599557 DOI: 10.1016/j.jamda.2019.01.133] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/13/2019] [Accepted: 01/15/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Advance care planning (ACP) is important to ensure that nursing home (NH) residents receive care concordant with their goals. Video interventions have been developed to improve the process of ACP. Yet, little is known about which NH characteristics are associated with implementation of ACP video interventions in clinical practice. Our objective was to examine NH-level characteristics associated with the implementation of an ACP video intervention as part of the Pragmatic trial of Video Education in Nursing Homes (PROVEN) trial. DESIGN Cross-sectional study of NHs in PROVEN. SETTING AND PARTICIPANTS 119 NHs randomized to receive the ACP video intervention. MEASUREMENTS The outcomes were the proportion of short- (<100 days) and long-stay (≥100 days) NH residents who were (1) offered to watch a video and (2) shown a video, aggregated to the NH-level, and measured using electronic forms of video offers. The association between outcomes and NH facility characteristics (eg, staffing, resident acuity) and participation in other aspects of the PROVEN trial (eg, monthly check-in calls) were estimated using multivariate linear regression models. NH characteristics were measured using data from Online Survey Certification and Reporting data, Long-term Care: Facts on Care in the US and NH Compare. RESULTS Offer rates were 69% [standard deviation (SD): 28] for short-stay and 56% (SD: 20) for long-stay residents. Show rates were 19% (SD: 21) for short-stay and 17% (SD: 17) for long-stay residents. After adjusting for NH characteristics, compared to 1-star NHs, higher star-rated NHs had higher offer rates. Champions' participation in check-in calls was positively associated with both outcomes for long-stay residents. CONCLUSIONS/IMPLICATIONS Lower-quality NHs seem unable to integrate a novel ACP video education program into routine care processes. Ongoing support for and engagement with NH staff to champion the intervention throughout implementation is important for the success of a pragmatic trial within NHs.
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Affiliation(s)
- Lacey Loomer
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI.
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI
| | - Emmanuelle Belanger
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI
| | - Jennifer A Palmer
- Hebrew Senior Life, Institute for Aging Research, Boston, MA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Susan L Mitchell
- Hebrew Senior Life, Institute for Aging Research, Boston, MA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Angelo E Volandes
- Section of General Medicine, Massachusetts General Hospital, Boston, MA
| | - Vincent Mor
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI; Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI; Center of Innovation in HSR&D, Providence Veterans Administration Medical Center, Providence, RI
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23
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Abstract
This study of Medicare claims analyzes utilization patterns for new Current Procedural Terminology codes for advance care planning visits.
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Affiliation(s)
- Emmanuelle Belanger
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
| | - Lacey Loomer
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - Susan L Mitchell
- Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Deepak Adhikari
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
| | - Pedro L Gozalo
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island.,Providence VA Medical Center, Providence, Rhode Island
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24
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Loomer L, Downer B, Thomas KS. Relationship between Functional Improvement and Cognition in Short-Stay Nursing Home Residents. J Am Geriatr Soc 2018; 67:553-557. [PMID: 30548843 DOI: 10.1111/jgs.15708] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/30/2018] [Accepted: 10/31/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Improving function is an important outcome of postacute care in skilled nursing facilities (SNFs), but cognitive impairment can limit a resident's ability to improve during a postacute care stay. Our objective was to examine the association between residents' cognitive status on admission and change in self-care and mobility during a Medicare-covered SNF stay. DESIGN Retrospective analysis of Medicare beneficiaries who had a new SNF stay between January and June 2017. SETTING SNFs in the United States. PARTICIPANTS Newly admitted residents with Medicare-covered SNF stays between January and June 2017 (n = 246 395). MEASUREMENTS Residents' self-care and mobility at SNF admission and discharge were determined using items from Section GG (eating, oral hygiene, toileting hygiene, sit to lying, lying to sitting, sit to stand, chair/bed transfer, and toilet transfer) of the Minimum Data Set. Residents were classified as cognitively intact, mildly impaired, moderately impaired, or severely impaired, according to the Cognitive Function Scale. Multivariable regression models controlling for residents' demographic and clinical characteristics and SNF fixed effects were used to identify residents whose discharge scores for self-care and mobility were better or the same as expected according to their cognitive status on admission. RESULTS Residents who were cognitively impaired on admission had lower functional status on admission and were less likely to improve in self-care and mobility compared with residents who were cognitively intact. Approximately 63% of residents who were cognitively intact had discharge scores for self-care and mobility that were better or the same as expected compared with 45% of residents with severe cognitive impairment. CONCLUSIONS Cognitive impairment is associated with poorer self-care and mobility function among SNF residents. These findings have important implications for clinicians, who may need additional support when caring for residents with cognitive impairment to make the same improvements in functional status as residents who are cognitively intact. J Am Geriatr Soc 67:553-557, 2019.
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Affiliation(s)
- Lacey Loomer
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Brian Downer
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas
| | - Kali S Thomas
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island.,Department of Veterans Affairs Medical Center, Providence, Rhode Island
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25
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McCreedy E, Mor V, Mitchell S, Loomer L. ESTABLISHING RATE OF CONVERSION FROM FULL CODE TO DO NOT RESUSCITATE STATUS AMONG LONG-STAY NURSING HOME RESIDENTS. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- E McCreedy
- Center for Gerontology and Healthcare Research, Brown University
| | - V Mor
- Brown University School of Public Health
| | | | - L Loomer
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
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26
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Palmer JA, Mor V, Volandes AE, McCreedy E, Loomer L, Carter P, Dvorchak F, Mitchell SL. A dynamic application of PRECIS-2 to evaluate implementation in a pragmatic, cluster randomized clinical trial in two nursing home systems. Trials 2018; 19:453. [PMID: 30134976 PMCID: PMC6106941 DOI: 10.1186/s13063-018-2817-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 07/21/2018] [Indexed: 11/10/2022] Open
Abstract
Background PRECIS-2 (PRagmatic Explanatory Continuum Indicator Summary-2) can assess how clinical trial design decisions (along the explanatory-pragmatic continuum) influence the applicability of trial results to intended stakeholders. The tool has been used to assess features of trials during the trial design phase and also upon completion. The ongoing PRagmatic trial Of Video Education in Nursing homes (PROVEN), which is evaluating the effectiveness of a suite of videos to improve advance care planning, is one of the first large pragmatic, cluster randomized trials within nursing home health care systems. While certain features of pragmatic trials remain static once designed (e.g., recruitment, outcomes), successful implementation of a system-wide program requires on-going evaluation and adaptation. This report’s objectives were to apply PRECIS-2 in a novel manner during the actual conduct of the PROVEN trial to assess how dynamic adaptations shifted implementation to either a more explanatory or a more pragmatic approach. Methods We assessed PROVEN’s protocol as initially designed according to the three PRECIS-2 domains pertinent to implementation: (1) Organization, (2) Flexibility-Delivery, and (3) Flexibility-Adherence. We then applied this framework to conduct a formative evaluation of decisions made while the trial was ongoing to adapt the implementation approach along the pragmatic versus the explanatory continuum in response to emergent challenges. Results Based on the PRECIS-2 rubric, the initial design of the PROVEN implementation approach reflected a hybrid of pragmatic and explanatory features. Most notably, within the Flexibility-Delivery, the trial had a relatively pragmatic approach to protocol delivery by front-line nursing home providers, balanced with a more explanatory approach to protocol monitoring enabled by the analytic capabilities of the research team. This more intensive monitoring proved critical in revealing implementation problems once the study began. Dynamic adaptations made in response to these challenges generally reflected shifts to more explanatory approaches within the Flexibility-Delivery and Flexibility-Adherence domains including ever more intensive compliance monitoring, as well as detailed coaching of front-line providers delivering the intervention by the research team. Conclusions Pragmatic trials conducted in the nursing home setting may benefit from a more dynamic approach to implementation. Allowing fluidity between pragmatic and explanatory features may still preserve the trial's applicability to intended stakeholders’ needs. PRECIS-2 provides a useful formative evaluation tool to assess these adaptations in “real-time.” Trial registration US National Library of Medicine, ClinicalTrials.gov, ID: NCT02612688. Registered on 19 November 2015
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Affiliation(s)
- Jennifer A Palmer
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA. .,Hebrew SeniorLife, Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA. .,Beth Israel Deaconess Medical Center, Department of Medicine, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA.,Providence Veterans Administration Medical Center, Center of Innovation in Health Services Research and Development Service, 830 Chalkstone Avenue, Providence, RI, 02908, USA
| | - Angelo E Volandes
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Massachusetts General Hospital, Section of General Medicine, 55 Fruit Street Gray 7-730, Boston, MA, 02114, USA
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA
| | - Phoebe Carter
- Hebrew SeniorLife, Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA
| | - Faye Dvorchak
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA
| | - Susan L Mitchell
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Hebrew SeniorLife, Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA.,Beth Israel Deaconess Medical Center, Department of Medicine, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA
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27
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Loomer L, Mitchell S, Mor V, Volandes A. P3‐532: ADVANCE CARE PLANNING FOR COGNITIVELY IMPAIRED INDIVIDUALS WITHIN THE NURSING HOME SETTING. Alzheimers Dement 2018. [DOI: 10.1016/j.jalz.2018.06.1897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Singh SR, Young GJ, Loomer L, Madison K. State-Level Community Benefit Regulation and Nonprofit Hospitals' Provision of Community Benefits. J Health Polit Policy Law 2018; 43:229-269. [PMID: 29630707 DOI: 10.1215/03616878-4303516] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Do nonprofit hospitals provide enough community benefits to justify their tax exemptions? States have sought to enhance nonprofit hospitals' accountability and oversight through regulation, including requirements to report community benefits, conduct community health needs assessments, provide minimum levels of community benefits, and adhere to minimum income eligibility standards for charity care. However, little research has assessed these regulations' impact on community benefits. Using 2009-11 Internal Revenue Service data on community benefit spending for more than eighteen hundred hospitals and the Hilltop Institute's data on community benefit regulation, we investigated the relationship between these four types of regulation and the level and types of hospital-provided community benefits. Our multivariate regression analyses showed that only community health needs assessments were consistently associated with greater community benefit spending. The results for reporting and minimum spending requirements were mixed, while minimum income eligibility standards for charity care were unrelated to community benefit spending. State adoption of multiple types of regulation was consistently associated with higher levels of hospital-provided community benefits, possibly because regulatory intensity conveys a strong signal to the hospital community that more spending is expected. This study can inform efforts to design regulations that will encourage hospitals to provide community benefits consistent with policy makers' goals.
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Saslow D, Andrews KS, Manassaram-Baptiste D, Loomer L, Lam KE, Fisher-Borne M, Smith RA, Fontham ETH. Human papillomavirus vaccination guideline update: American Cancer Society guideline endorsement. CA Cancer J Clin 2016; 66:375-85. [PMID: 27434803 PMCID: PMC5555157 DOI: 10.3322/caac.21355] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Answer questions and earn CME/CNE The American Cancer Society (ACS) reviewed and updated its guideline on human papillomavirus (HPV) vaccination based on a methodologic and content review of the Advisory Committee on Immunization Practices (ACIP) HPV vaccination recommendations. A literature review was performed to supplement the evidence considered by the ACIP and to address new vaccine formulations and recommendations as well as new data on population outcomes since publication of the 2007 ACS guideline. The ACS Guideline Development Group determined that the evidence supports ACS endorsement of the ACIP recommendations, with one qualifying statement related to late vaccination. The ACS recommends vaccination of all children at ages 11 and 12 years to protect against HPV infections that lead to several cancers and precancers. Late vaccination for those not vaccinated at the recommended ages should be completed as soon as possible, and individuals should be informed that vaccination may not be effective at older ages. CA Cancer J Clin 2016;66:375-385. © 2016 American Cancer Society.
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Affiliation(s)
- Debbie Saslow
- Director, Cancer Control Intervention, Human Papillomavirus and Women’s Cancers, American Cancer Society, Atlanta, GA
| | | | | | - Lacey Loomer
- Graduate Student, Emory University Rollins School of Public Health, Atlanta, GA
| | - Kristina E. Lam
- Medical Epidemiologist, Georgia Department of Public Health, Atlanta, GA
| | - Marcie Fisher-Borne
- Program Director, Human Papillomavirus Vaccination, American Cancer Society, Atlanta, GA
| | - Robert A. Smith
- Vice President, Cancer Screening, American Cancer Society, Atlanta, GA
| | - Elizabeth T. H. Fontham
- Founding Dean and Professor Emeritus, Louisiana State University School of Public Health, New Orleans, LA
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Schaberg SJ, Daniels CA, Loomer L, Addante RR. Bilateral hard palate masses. J Oral Maxillofac Surg 1993; 51:1262-7. [PMID: 7693900 DOI: 10.1016/s0278-2391(10)80299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Abstract
PURPOSE The administration of amphotericin B in the conventional prolonged infusion over 4 to 6 hours is complicated by the acute toxicities of fevers and chills in 50% to 90% of patients and the chronic toxicities of increased creatinine levels and hypokalemia in 60% to 80% of patients. To determine the safety and toxicity of rapid infusions, we conducted a prospective, nonrandomized study in patients with clinical indications for antifungal therapy. PATIENTS AND METHODS Twenty-five granulocytopenic adults with acute leukemia and myelodysplastic syndromes were enrolled in a phase I trial using four sequentially shorter infusion durations: a standard infusion over 4 hours (n = 3) and shortened infusion durations at 3 hours (n = 3), 2 hours (n = 4), and 1 hour (n = 15). Toxicity was assessed by daily examinations of study subjects by one of the study investigators, by documentation of all infusion-related fevers and chills, and by daily monitoring of serum levels of creatinine, potassium, magnesium, and aspartate aminotransferase. RESULTS Temperatures greater than 38 degrees C occurred in 16 of 25 (64%) patients, but only two had temperatures exceeding 40 degrees C. Chills were observed in 13 of 25 (56%) patients, but only one had severe symptoms. Serum creatinine increased more than 0.5 mg/dL (44.20 mumol/L) above the pretreatment baseline in 17 of 25 (68%) patients, and the absolute creatinine level was greater than or equal to 2.0 mg/dL (176.8 mumol/L) in 10 of 25 (40%) patients. Serum potassium levels dropped below the normal limit of 3.5 mEq/L (3.5 mmol/L) in all patients, but no patient had potassium levels below 2.5 mEq/L (2.5 mmol/L). Intravenous potassium supplementation was administered to all patients and exceeded 100 mEq/d in 12 of 25 (48%) patients. CONCLUSIONS Rapid infusions of amphotericin B are safe, are associated with similar toxicity as prolonged infusions, and facilitate inpatient care by decreasing nursing time needed for administration and minimizing scheduling conflicts with other necessary intravenous medications. Shorter infusions also facilitate outpatient and home administration of amphotericin B.
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Affiliation(s)
- J M Cruz
- Section on Oncology, Wake Forest University, Bowman Gray School of Medicine, Winston-Salem, North Carolina 27103
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Abstract
Eighty clinical oncologists in the southeastern United States were surveyed to determine their strategies for follow-up care after primary treatment of early-stage breast cancer. The frequency of use of the history and physical examination, complete blood count, liver function tests, carcinoembryonic antigen levels, chest x-ray, skeletal survey, bone scan, liver scan, and mammogram for observing hypothetical low- and high-risk patients was assessed. Yearly mammograms were recommended by more than 95% of respondents. History and physical examination were the modalities used most often, whereas periodic bone and liver scans were used only in a minority of patients. A review of the literature supported the strategy of the respondents in this survey and further underscored the cost-effectiveness of the history and physical examination in detecting recurrence during follow-up. Based on this survey and supporting literature, recommendations for reasonable yet cost-conscious follow-up are presented.
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Affiliation(s)
- L Loomer
- Department of Medicine, Bowman Gray School of Medicine, Winston-Salem, NC 27103
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McCullough DL, Cooper RM, Yeaman LD, Loomer L, Woodruff RD, Boyce WH, Harrison LH, Assimos DG, Lynch DF. Neoadjuvant treatment of stages T2 to T4 bladder cancer with cis-platinum, cyclophosphamide and doxorubicin. J Urol 1989; 141:849-52. [PMID: 2926878 DOI: 10.1016/s0022-5347(17)41030-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In an ongoing phase II study 17 patients with potentially operable transitional cell carcinoma of the bladder (stages T2 to T4, Nx, Mo) have been treated with intravenous cis-platinum (50 mg.per m.2), cyclophosphamide (400 mg.per m.2) and doxorubicin (40 mg.per m.2). They were to receive 3 treatments at 3-week intervals before cystectomy and 2 treatments at 3-week intervals commencing 5 weeks after cystectomy. Of 17 patients 14 (82 per cent) completed all 3 preoperative treatments but only 7 (41 per cent) continued on to complete the entire 5 treatments. In most cases incomplete therapy was due to patient refusal. Toxicity was low as measured by World Health Organization standards. Of the 17 patients 9 (53 per cent) exhibited objective tumor response (pathological downstaging or greater than 50 per cent reduction of tumor volume determined by either computerized tomography scan and/or endoscopic examination. When the determination was made by endoscopy the changes were dramatic and not borderline.) No patient demonstrated a pathological complete response. All 9 of the responders (100 per cent) remain clinically free of disease at a median follow-up of 19 months (range 4 to 30 months). The 8 nonresponders have done poorly with 5 dead of disease, 1 alive with pelvic recurrence and 2 free of disease at 4 and 12 months. These tumor response rates compare favorably with other cis-platinum-based combination regimens. The response to the chemotherapy appears to be an important prognostic indicator. Phase III trials must be conducted to determine whether this neoadjuvant chemotherapy regimen has a significant effect on long-term patient survival.
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Affiliation(s)
- D L McCullough
- Department of Surgery, Bowman Gray School of Medicine, Winston-Salem, North Carolina
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