Journal of the American Medical Directors Association最新文献

With increased focus on antimicrobial stewardship in post-acute, long-term care (PALTC) settings, optimization of diagnostic testing is essential. Molecular diagnostics are currently being offered and used for the diagnosis of urinary tract infections (UTIs) in community and PALTC settings. Yet, no studies to date explore the role of rapid diagnostics such as polymerase chain reaction and other molecular methods in the stewardship efforts of PALTC settings, specifically compared with standard testing with urinalysis and culture with antimicrobial susceptibility testing. This article outlines a framework of diagnostic stewardship to critically evaluate the use of molecular diagnostics for the diagnosis of UTIs in PALTC and the impact on patient outcomes and antimicrobial stewardship. The authors suggest a 5-step process for evaluating the role of novel diagnostics in the PALTC setting. Understanding the shortcomings of newer diagnostic tests may identify needs for further investigation before their widespread use.

Objectives

Design

Setting and Participants

Methods

Results

Conclusions and Implications

Objectives

Some studies reported a relationship between life-space mobility (LSM) and frailty assessed by physical aspects; however, a more comprehensive discussion of frailty is underdeveloped. In addition, previous studies have focused only on older Euro-American people. Therefore, we aimed to examine LSM-frailty relationships in community-dwelling older Japanese persons using physical and comprehensive frailty indices.

Design

A cross-sectional study.

Setting and Participants

We used the data of 8898 older adults from a baseline survey of the Kyoto-Kameoka Study in Japan.

Methods

The validated life-space assessment (LSA) was used to evaluate LSM and categorized it into quartiles. Two validated indices were used to evaluate frailty: the Kihon Checklist (KCL) and the simple Frailty Screening Index (FSI). Multivariable logistic regression was used to determine the relationships between LSM scores and frailty.

Results

The mean age (SD) of the participants was 73.4 (6.3) years, and 53.3% were women. The mean LSM score of the study participants was 53.0. The prevalence of frailty by KCL and FSI was 40.7% and 16.8%, respectively. Significant differences between LSM score and frailty prevalence were observed [KCL: Q1, reference; Q2, odds ratio (OR) 0.53, 95% CI 0.45–0.62; Q3, OR 0.30, 95% CI 0.25–0.35; Q4: OR 0.22, 95% CI 0.18–0.26, P for trend <.001; FSI: Q1, reference; Q2, OR 0.57, 95% CI 0.48–0.68; Q3: OR 0.38, 95% CI 0.31–0.46; Q4: OR 0.35, 95% CI 0.28–0.42, P for trend <.001]. Similar results were observed when LSM scores were examined at 10-point intervals, with LSM and frailty exhibiting an L-shaped relationship. The LSM score dose-response curve at which the OR for frailty plateaued among older individuals was approximately 81–90 score.

Conclusions and Implications

LSM score and frailty prevalence exhibited L-shaped relationships in community-dwelling older persons. This study's findings provide useful data for setting LSM targets for preventing frailty in community-dwelling older persons.

In decision making for cancer treatment, information is crucial for patients and health care professionals. Although conversations about treatment decisions take place in hospitals, many patients also appreciate the insights of their general practitioner (GP). GPs indicated that, in order to have meaningful conversations about treatment decisions with their patients, they need additional information about treatment options and considerations, such as expected benefits and side effects.

In this practice innovation, we developed and implemented a new written communication format from medical specialists to GPs, aimed at providing accurate treatment information to facilitate GPs in supporting patients with cancer in decision-making. The new format added 3 specific headings to standard letters in the electronic patient files (EPFs): (1) treatment options, (2) treatment considerations, and (3) treatment intent.

This innovation was implemented in a large university hospital in the Netherlands between 2020 and 2021. We performed a process evaluation of the implementation using the RE-AIM model, based on assessment of written communication obtained from patients’ EPFs, and telephonic interviews with specialists and GPs.

In the Netherlands, all inhabitants are registered with a GP, who acts as a gatekeeper to specialist care, and has a comprehensive overview of a patient’s history, based on digital communication with hospitals after referral for specialist care. EPFs are used to generate digital letters to communicate between medical specialists in a hospital and GPs outside the hospital. Incorporating new headings in the communication format in the EPF successfully encouraged medical specialists to share such information when used appropriately. Treatment options, considerations, and treatment intent were stated more often in the new format compared with the old format. GPs appreciated the new format, highlighting the value of including treatment considerations, which enhanced their comprehension of the medical specialist's thought processes.

Recognition of the problem and motivation for improvement facilitated the implementation. Specialists stated the format to be time-efficient compared with the old format; however, technical improvements could make it easier to use. Automaticity to use of the old format, inadequate information, and technical issues were a barrier for implementation.

In summary, a straightforward innovation can improve communication between medical specialists and GPs and promote the role of the GPs in decision making for cancer treatment.

Objectives

To systematically examine the evidence of the association between extreme weather events (EWEs) and adverse health outcomes among short-stay patients undergoing post-acute care (PAC) and long-stay residents in nursing homes (NHs).

Design

This is a scoping review. The findings were reported using the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews checklist.

Settings and Participants

Studies published on short-stay PAC and long-stay residents in NHs.

Methods

A literature search was performed in 6 databases. Studies retrieved were screened for eligibility against predefined inclusion and exclusion criteria. Studies were qualitatively synthesized based on the EWE, health outcomes, and special populations studied.

Results

Of the 5044 studies reviewed, 10 met our inclusion criteria. All were retrospective cohort studies. Nine studies examined the association between hurricane exposure, defined inconsistently across studies, and PAC patients and long-stay residents in the NH setting in the Southern United States; the other study focused on post-flood risk among North Dakota NH residents. Nine studies focused on long-stay NH residents receiving custodial care, and 1 focused on patients receiving PAC. Outcomes examined were unplanned hospitalization rates and mortality rates within 30 and 90 days and changes in cognitive impairment. Nine studies consistently found an association between hurricane exposure and increased risk of 30- and 90-day mortality compared to unexposed residents.

Conclusions and Implications

Of the EWEs examined, hurricanes are associated with an increased risk of mortality among long-stay NH residents and those admitted to hospice, and with increased risk of hospitalization for short-stay PAC patients. As the threat of climate-amplified EWEs increases, future studies of NH residents should evaluate the impact of all types of EWEs, and not solely hurricanes, across wider geographic regions, and include longer-term health outcomes, associated costs, and analyses of potential disparities associated with vulnerable populations in NHs.

Objectives

Physical and cognitive conditions of patients discharged to skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home with home health agencies (HHAs) following total joint arthroplasty (TJA) have not been evaluated. The purpose of this study is to examine the physical and cognitive function trends of Medicare beneficiaries discharged to SNFs, HHAs, and IRFs following TJA from 2013 to 2018.

Design

Observational study using Medicare enrollment, claims, and assessment data from 2013–2018.

Setting and Participants

1,278,939 Medicare beneficiaries discharged to SNFs, HHAs, or IRFs for post-acute care following TJA from 2013 to 2018.

Methods

Medicare data were used to examine the association between the endpoints of interest [discharge destination (SNF, HHA, or IRF) and the physical (measured using activities of daily living) and cognitive (measured using a range of setting-specific metrics) status of patients in each setting] and the year of TJA (2013–2018) by estimating multivariable models that controlled for patient- and hospital-level covariates.

Results

Multivariable analysis of 1,278,939 TJAs revealed that SNF discharge decreased [44.15% (2013)–21.57% (2018), P < .001], HHA increased (46.72%–72.47%, P < .001), and IRF decreased (9.13%–5.69%, P < .001). For SNF, the mean physical function scores [14.61 (2013)–14.23 (2018), P < .001] and cognitive impairment (13.25%–12.33%, P = .01) decreased, indicating less dependence. Physical function scores (3.09–3.94, P < .001) and cognitive impairment (13.95%–16.52%, P < .001) increased for HHA patients, indicating greater dependence. For IRF, motor functional independence measure decreased (38.81–37.78, P < .001) and cognitive dependence increased (39.08%–46.36%, P < .001), indicating greater dependence.

Conclusions and Implications

From 2013 to 2018, patients were increasingly discharged to HHA. Although SNF patients were less dependent over time, HHA and IRF patients were physically and cognitively more dependent. Each setting is likely to benefit from policy and fiscal supports that help them manage changes in the volume and clinical intensity of patients requiring their services.

Objectives

End-of-life (EOL) transitions to hospital can be burdensome for older adults and may contribute to poor outcomes. We investigated the association of disease trajectory and place of care with EOL burdensome transitions.

Design

Retrospective cohort study using administrative data.

Setting/Participants

Ontarians aged ≥65 years who died between 2015 and 2018 and received long-term care (LTC) or home care 6 months before death.

Methods

Disease trajectories were defined based on EOL functional decline: terminal illness, organ failure, frailty, sudden death, and other. Places of care included LTC, EOL home care, and non-EOL home care. Burdensome transitions were defined as early (≥3 hospitalizations for any reason or ≥2 hospitalizations due to pneumonia, urinary tract infection, sepsis, or dehydration in the last 90 days of life) or late (≥1 hospitalizations for any reason in the last 3 days of life). Multinomial logistic regression tested for effect modification between disease trajectory and places of care on burdensome transitions.

Results

Of 110,776 decedents, 40.7% had organ failure, 37.5% had frailty, and 12.8% had a terminal illness, with the remainder in sudden death or other categories. Most were in LTC (62.5%), and 37.5% received home care, with 6.8% receiving designated EOL home care and 30.7% non-EOL home care. There was a significant interaction (P < .001) between disease trajectory and care settings. Compared with terminal illness, organ failure was associated with increased odds of early transitions across all care settings [odds ratios (ORs) ranging 1.14-1.21]. Frailty was associated with increased odds of early transitions solely for non-EOL home care recipients (OR 1.17, 95% CI 1.06-1.28). Organ failure and frailty were associated with increased odds of late transitions across all settings, with organ failure having greater odds in LTC (organ failure OR 2.29, 95% CI 2.02-2.60, vs frailty OR 1.79, 95% CI 1.58-2.04).

Conclusions and Implications

Disparities exist in burdensome transitions, notably for noncancer decedents with organ failure in LTC. Enhancing palliative care may help reduce burdensome transitions and improve patient outcomes.

Objectives

This study aims to investigate the relationship between frailty and avoidable hospitalization risk, and the moderating role of sociodemographic, clinical, and care-related factors.

Design

Longitudinal population-based cohort study.

Setting and Participants

A total of 3168 community-dwelling individuals, aged ≥60 years, from the Swedish National study on Aging and Care in Kungsholmen (SNAC-K).

Methods

We operationalized physical frailty using baseline SNAC-K data (2001-2004). In line with the Swedish Board of Health and Welfare and Association of Local Authorities and Regions, avoidable hospitalizations were considered those that could have been prevented through proper and timely outpatient care and identified through the Swedish National Patient Register. Participants were followed from baseline until first avoidable hospitalization, death, drop out, institutionalization, or maximum 12 (median 7.6) years. The association between frailty and avoidable hospitalization was explored through flexible parametric survival models, with stratified analyses to investigate age, gender, education, civil status, multimorbidity, cognitive status, and informal and formal care as potential modifiers.

Results

The adjusted 12-year cumulative incidence of avoidable hospitalization was significantly higher for frail persons (cumulative incidence 33.2%, 95% CI 28.9%-38.1%) than for prefrail (cumulative incidence 26.6%, 95% CI 24.5%-29.0%) and nonfrail (cumulative incidence 25.2%, 95% CI 22.5%-28.3%) individuals. In addition, prefrailty [hazard ratio (HR) 1.21, 95% CI 1.00-1.45] and frailty (HR 1.91, 95% CI 1.47-2.50) were associated with increased avoidable hospitalization hazards. Furthermore, the association between frailty and avoidable hospitalization was stronger in older adults aged <78 years (HR 3.12, 95% CI 1.99-4.91) and those with relatively fewer chronic diseases (HR 3.88, 95% CI 1.95-7.72), whereas provision of formal social care (HR 1.15, 95% CI 0.77-1.72) seemed to act as a buffer.

Conclusions and Implications

Our results indicate that older community-dwelling adults with prefrailty and frailty are at increased risk of experiencing avoidable hospitalizations, highlighting a need for better care of these individuals at the outpatient level. Formal social care services and close monitoring of particularly vulnerable subgroups of frail persons may mitigate this risk.

Objectives

To determine the feasibility of conducting a trial of a novel nighttime lighting system designed to support postural stability in assisted living (AL) residents, and to estimate intervention effectiveness by comparing the incidence of nighttime falls during the novel lighting condition to that in a control condition featuring a standard nightlight.

Design

Randomized crossover trial. The intervention consisted of 3 custom-designed linear arrays of amber light-emitting diodes (LEDs) arranged in strips: 1 strip aligned horizontally across the top of the bathroom/entry doorframe containing 68 LEDs and 2 strips of 140 LEDs each aligned vertically down the sides of the doorframe. The control condition was 1 standard nightlight in the bedroom and 1 in the bathroom. Residents were randomized to treatment sequences, receiving each condition for 1-2 quarters.

Setting and Participants

Five AL communities serving exclusively residents with dementia or having separate units for residents with dementia, with at least 30 beds and at least 5 residents in private rooms. Residents were eligible if they had dementia, were ambulatory, did not share a bedroom, were not on hospice or expected to die within the year, and were not expected to transfer to another setting within the year.

Methods

Outcomes included recruitment, retention, incident falls, and satisfaction.

Results

Thirty-eight residents of the 5 communities participated (56% recruitment rate), and 24 family members completed surveys about their satisfaction with the lighting system. Cameras captured falls data for 92% of 8591 resident nights. The incidence density for falls was 34% lower in the intervention condition than the control condition (incidence density ratio 0.66, 95% CI 0.35, 1.22), which did not reach statistical significance (P = .18).

Conclusions and Implications

This low-cost intervention was feasible with high satisfaction. Building on these results, the intervention is being evaluated in a larger clinical trial. A novel lighting system to reduce falls could ultimately benefit millions of older adults across all settings.