PURPOSE OF THE STUDY: To (a) describe A Scheduled Shifts Staffing measure (ASSiST) to derive care aide worked hours per resident day (HCA WHRD) at facility and unit levels in nursing homes, (b) report reliability through comparisons to administrative staffing data; (c) report validity by examining associations between HCA WHRD, staff outcomes (job satisfaction, emotional exhaustion), and resident quality indicators (QIs) (e.g. falls, delirium, stage 2+ pressure ulcers), and (d) explore intrafacility variation in staffing intensity levels related to unit-level variation in resident and staff outcomes. DESIGN AND METHODS: We used data from 40 care units in 12 Canadian nursing homes between 2007 and 2012. Descriptive statistics and tests of association and difference described relationships of two measures of staffing with resident and staff outcomes. RESULTS: Annualized rates of HCA WHRD from both data sources compared well at the facility level (Pearson Product Correlation; R = 0.847, p < .001), and were correlated similarly to staff work life and many QIs. Using ASSiST data, we show that staffing levels can vary by up to 40% at the unit-level within nursing homes. IMPLICATIONS: ASSiST is easy to collect, more timely to retrieve than administrative data, has good criterion and construct validity, and reflects intrafacility variation in health care aide staffing levels.
New article by Dr. Jo Rycroft Malone
Collective action for implementation: a realist evaluation of organisational collaboration in healthcare
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BACKGROUND: Increasingly, it is being suggested that translational gaps might be eradicated or narrowed by bringing research users and producers closer together, a theory that is largely untested. This paper reports a national study to fill a gap in the evidence about the conditions, processes and outcomes related to collaboration and implementation. METHODS: A longitudinal realist evaluation using multiple qualitative methods case studies was conducted with three Collaborations for Leadership in Applied Health Research in Care (England). Data were collected over four rounds of theory development, refinement and testing. Over 200 participants were involved in semi-structured interviews, non-participant observations of events and meetings, and stakeholder engagement. A combined inductive and deductive data analysis process was focused on proposition refinement and testing iteratively over data collection rounds. RESULTS: The quality of existing relationships between higher education and local health service, and views about whether implementation was a collaborative act, created a path dependency. Where implementation was perceived to be removed from service and there was a lack of organisational connections, this resulted in a focus on knowledge production and transfer, rather than co-production. The collaborations’ architectures were counterproductive because they did not facilitate connectivity and had emphasised professional and epistemic boundaries. More distributed leadership was associated with greater potential for engagement. The creation of boundary spanning roles was the most visible investment in implementation, and credible individuals in these roles resulted in cross-boundary work, in facilitation and in direct impacts. The academic-practice divide played out strongly as a context for motivation to engage, in that ‘what’s in it for me’ resulted in variable levels of engagement along a co-operation-collaboration continuum. Learning within and across collaborations was patchy depending on attention to evaluation. CONCLUSIONS: These collaborations did not emerge from a vacuum, and they needed time to learn and develop. Their life cycle started with their position on collaboration, knowledge and implementation. More impactful attempts at collective action in implementation might be determined by the deliberate alignment of a number of features, including foundational relationships, vision, values, structures and processes and views about the nature of the collaboration and implementation.
Comprehensive public health action on population ageing is urgently needed. This will require fundamental shifts, not just in the things we do, but in how we think about ageing itself. The World report on ageing and health outlines a framework for action to foster Healthy Ageing built around the new concept of functional ability. Making these investments will have valuable social and economic returns, both in terms of health and wellbeing of older people and in enabling their on-going participation in society.
Calls for Abstracts
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Canadian Association on Gerontology (CAG)
CAG2016 is your opportunity to share your research and other work in the field of aging with your national and international colleagues from a diverse spectrum of disciplines. Abstracts are welcomed from all disciplines and all interests in aging, including research, practice, policy and related areas. International submissions are encouraged.
The Journal of Nursing Scholarship invites authors to contribute original research articles as well as review articles that address the development, evaluation, or implementation of innovative care models in residential long-term care including models* shaping the transitions between different settings.
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The selected organization or research team will use a consultative process that effectively engages citizens while establishing research priorities, preferably using a process consistent with the James Lind Alliance (JLA) Protocol to establish research priorities. This Research Priority Setting Process will bring patients and clinicians together to identify uncertainties about medical care management (i.e., diagnosis, prognosis, and treatment) relating to health care of frail older Canadians, across the spectrum of care settings, including those at end of life. Participants will agree by consensus a prioritized list of ten (10) to fifteen (15) unanswered questions regarding medical care management.
Policy makers view academic healthcare organisations as important to healthcare innovation because they act as boundary-spanning organisations that integrate science and care institutional logics. Institutional logics are implicit and socially shared rules of the game that prescribe behaviour within a social group. This paper explores how individuals affiliated with academic healthcare organisations negotiate science and care institutional logics within their day-to-day work through a qualitative case study of research and healthcare within academic healthcare organisations in Vancouver, Canada. It highlights that there is less hybridisation of institutional logics than policy makers might hope: some researchers hosted in academic healthcare organisations are not part of the care institutional logic, others are not well integrated with the research institutional logic. Clinician–scientists often struggle to integrate the science and care institutional logics in their day-to-day work; other workers do integrate science and care institutional logics through experiments of nature but their research may not be viewed as high quality science. Because of poor hybridisation, academic healthcare organisations may not be as effective in facilitating healthcare innovation as policy makers assume.
BACKGROUND: Network partnerships between public health and third sector organisations are being used to address the complexities of population level social determinants of health and health equity. An understanding of how these networks use research and knowledge is crucial to effective network design and outcome evaluation. There is, however, a gap in the literature regarding how public health networks use research and knowledge. The purpose of this paper is to report on the qualitative findings from a larger study that explored (1) the experiences of public health networks with using research and knowledge, and (2) the perceived benefits of using research and knowledge. METHODS: A multiple case study approach framed this study. Focus group data were collected from participants through a purposive sample of four public health networks. Data were analyzed using Framework Analysis and Nvivo software supported data management. Each network had the opportunity to participate in data interpretation. RESULTS: All networks used published research studies and other types of knowledge to accomplish their work, although in each network research and knowledge played different but complementary roles. Neither research nor other types of knowledge were privileged, and an approach that blended varied knowledge types was typically used. Network experiences with research and knowledge produced individual and collective benefits. A novel finding was that research and knowledge were both important in shaping network function. CONCLUSIONS: This study shifts the focus in the current literature from public health departments to the community setting where public health collaborates with a broader spectrum of actors to ameliorate health inequities. Both formal research and informal knowledge were found to be important for collaborative public health networks. Examining the benefits of research and knowledge use within public health networks may help us to better understand the relationships among process (the collaborative use of research and knowledge), structure (networks) and outcomes (benefits).
BACKGROUND: Understanding the motivations and perspectives of providers in following guidance and evidence-based policies can contribute to the evidence on how to better implement and deliver care, particularly in resource-constrained settings. This study explored how providers’ attitudes and behaviors influenced the implementation of an intervention, provider-initiated HIV testing and counseling, in primary health care settings in Botswana. METHODS: Using a grounded-theory approach, we purposively selected and interviewed 45 providers in 15 facilities in 3 districts and inductively analyzed data for themes and patterns. RESULTS: We found that nurses across facilities and districts were largely resistant to offering and delivering provider-initiated testing and counseling for HIV (PITC) for three reasons: (1) they felt they were overworked and had no time, (2) they felt it was not their job, and (3) they were afraid to counsel patients, particularly fearing a positive HIV test. These factors were largely related to health system constraints that affected the capacity of providers to do their job. An important underlying themes emerged: nurses and lay counselors were unsatisfied with pay and career prospects, which made them unmotivated to work in general. Variations were seen by urban and rural areas: nurses in urban areas felt generally overworked and PITC was seen as contributing to the workload. While nurses in rural areas did not feel overworked, they felt that PITC was not their job and they were unmotivated because of general unhappiness with their rural posts. CONCLUSIONS: The attitudes and behaviors of providers and barriers they faced played a critical role in whether and how PITC was being implemented in Botswana. Provider factors should be considered in the improvement of existing PITC programs and design of new ones. Addressing constraints faced by providers can do more to improve supply of human resources than merely recruiting more providers.
BACKGROUND: In 2012 and 2013, we conducted a social network survey of a new translational research network (TRN) designed to deliver better care to cancer patients. Results of these two surveys showed that silos of researchers and clinicians existed before the TRN was established but that the network had mediated collaborative relationships. This paper reports on a third social network survey of the TRN and focusses on the structure of the collaborative arrangements among members. METHODS: Members of the TRN were invited to complete an on-line, whole network survey in May 2015. The survey asked respondents to identify personal impacts, outputs and wider outcomes attributable to their TRN membership. The final question asked respondents to select the name of TRN members with whom they had collaborated either formally or informally. For each member nominated, they were asked to say whether they had known this person before joining the TRN. RESULTS: Response rate was 70 %. Over 4 years, the TRN has grown in size from 68 to 244 members. Relationships within and across the TRN have become more collaborative and interactive, with 1658 collaborative ties between members and over 40 % of ties with people unknown to participants before they joined the TRN. This points to a well-functioning network which has retained its focus on the original goals of the TRN and has fostered collaboration between researchers, clinicians, managers, consumers and TRN operational staff. This survey shows that the TRN’s impact goes beyond outcomes from formal TRN-funded projects. About one third of respondents could list projects not directly funded by the TRN but which are attributed to TRN membership. Examples of practice change brought about through the TRN were given by 77 % of respondents. A substantial risk factor for the future is the high levels of dependency on key or central TRN participants. CONCLUSIONS: The structure of the TRN with its active central actors and brokers has been able to foster collaboration on implementation initiatives that result in practice change. The role of a social professional network in driving this collaboration is shown.
BACKGROUND: In healthcare research, results diffuse only slowly into clinical practice, and there is a need to bridge the gap between research and practice. This study elucidates how healthcare professionals in a hospital setting experience working with the implementation of research results. METHOD: A descriptive design was chosen. During 2014, 12 interviews were carried out with healthcare professionals representing different roles in the implementation process, based on semi-structured interview guidelines. The analysis was guided by a directed content analysis approach. RESULTS: The initial implementation was non-formalized. In the decision-making and management process, the pattern among nurses and doctors, respectively, was found to be different. While nurses’ decisions tended to be problem-oriented and managed on a person-driven basis, doctors’ decisions were consensus-oriented and managed by autonomy. All, however, experienced a knowledge-based execution of the research results, as the implementation process ended. CONCLUSION: The results illuminate the challenges involved in closing the evidence-practice gap, and may add to the growing body of knowledge on which basis actions can be taken to ensure the best care and treatment available actually reaches the patient.
OBJECTIVES: Translating research evidence into routine clinical practice is notoriously difficult. Behavioural interventions are often used to change practice, although their success is variable and the characteristics of more successful interventions are unclear. We aimed to establish the characteristics of successful behaviour change interventions in healthcare. DESIGN: We carried out a systematic overview of systematic reviews on the effectiveness of behaviour change interventions with a theory-led analysis using the constructs of normalisation process theory (NPT). MEDLINE, CINAHL, PsychINFO and the Cochrane Library were searched electronically from inception to July 2015. SETTING: Primary and secondary care. PARTICIPANTS: Participants were any patients and healthcare professionals in systematic reviews who met the inclusion criteria of having examined the effectiveness of professional interventions in improving professional practice and/or patient outcomes. INTERVENTIONS: Professional interventions as defined by the Cochrane Effective Practice and Organisation of Care Review Group. PRIMARY AND SECONDARY OUTCOME MEASURES: Success of each intervention in changing practice or patient outcomes, and their mechanisms of action. Reviews were coded as to the interventions included, how successful they had been and which NPT constructs its component interventions covered. RESULTS: Searches identified 4724 articles, 67 of which met the inclusion criteria. Interventions fell into three main categories: persuasive; educational and informational; and action and monitoring. Interventions focusing on action or education (eg, Audit and Feedback, Reminders, Educational Outreach) acted on the NPT constructs of Collective Action and Reflexive Monitoring, and reviews using them tended to report more positive outcomes. CONCLUSIONS: This theory-led analysis suggests that interventions which contribute to normative restructuring of practice, modifying peer group norms and expectations (eg, educational outreach) and relational restructuring, reinforcing modified peer group norms by emphasising the expectations of an external reference group (eg, Reminders, Audit and Feedback), offer the best chances of success. Combining such interventions is most likely to change behaviour.
Health Care Administration and Organization
OBJECTIVES: To identify, assess and summarize available scientific evidence about the effect of interventions deployed by advanced practice nurses when providing care to older people in different care settings, and to describe the roles and components of the interventions developed by these professionals. BACKGROUND: In older people, evidence of advanced practice roles remains dispersed along different contexts, approaches and settings; there is little synthesis of evidence, and it is not easy to visualize the different practice models, their components, and their impact. DESIGN: Systematic review. DATA SOURCES: Sixteen electronic databases were consulted (1990-2014). The research also included screening of original studies in reviews and reports from Centers of Health Services Research and Health Technology Agencies. REVIEW METHODS: Studies were assessed by two reviewers with the Cochrane risk of bias tool. They were classified depending on the type of follow-up (long and short-term care) and the scope of the service (advanced practice nurses interventions focused on multimorbid patients, or focused on a specific disease). RESULTS: Fifteen studies were included. In long-term settings, integrative, multi-component and continuous advanced practice nursing care, reduced readmissions, and increased patients’ and caregivers’ satisfaction. Advanced practice nurses were integrated within multidisciplinary teams and the main interventions deployed were patient education, multidimensional assessments and coordination of multiple providers. CONCLUSION: Positive results have been found in older people in long-term care settings, although it is difficult to discern the specific effect attributable to them because they are inserted in multidisciplinary teams. Further investigations are needed to evaluate the cost-effectiveness of the two modalities detected and to compare internationally the interventions developed by advanced practice nurses.
BACKGROUND: The Institute of Medicine’s Future of Nursing report identifies the clinical nurse leader as an innovative new role for meeting higher health-care quality standards. However, specific clinical nurse leader practices influencing documented quality outcomes remain unclear. Lack of practice clarity limits the ability to articulate, implement and measure clinical nurse leader-specific practice and quality outcomes. PURPOSE AND METHODS: Interpretive synthesis design and grounded theory analysis were used to develop a theoretical understanding of clinical nurse leader practice that can facilitate systematic and replicable implementation across health-care settings. RESULTS: The core phenomenon of clinical nurse leader practice is continuous clinical leadership, which involves four fundamental activities: facilitating effective ongoing communication; strengthening intra and interprofessional relationships; building and sustaining teams; and supporting staff engagement. CONCLUSION: Clinical nurse leaders continuously communicate and develop relationships within and across professions to promote and sustain information exchange, engagement, teamwork and effective care processes at the microsystem level. IMPLICATION FOR NURSING MANAGEMENT: Clinical nurse leader-integrated care delivery systems highlight the benefits of nurse-led models of care for transforming health-care quality. Managers can use this study’s findings to frame an implementation strategy that addresses theoretical domains of clinical nurse leader practice to help ensure practice success.
AIM: This study examined the contributions of perceived organisational support (POS) and organisational commitment (i.e. affective, continuance and normative) to self-competence among nurses. BACKGROUND: In high-POS environments, workers benefit from socio-emotional resources to improve their skills, while positive forms of commitment (e.g. affective commitment) create a fertile context for developing one’s competencies. METHODS: A cross-sectional study was conducted among the nursing staff of two Italian urban hospitals (hospital A, n = 160; hospital B, n = 192). A structured questionnaire was administered individually to the nurses. Data analysis was conducted through multi-group analysis and supplemented by a bootstrapping approach. RESULTS: The results showed that POS was positively related to self-competence through affective commitment. In contrast, continuance and normative commitment did not mediate this relationship. CONCLUSIONS: This study shows that supporting employees through caring about their well-being as well as fostering positive forms of organisational commitment increases nurses’ self-competence. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers may increase support perceptions and commitment among their staff by rewarding their contributions and caring about their well-being, as well as concentrating on training strategies that improve work-related skills.
Health Care Innovation and Quality Assurance
Development and usability of the MAINtAIN, an inventory assessing nursing staff behavior to optimize and maintain functional activity among nursing home residents: a mixed-methods approach
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BACKGROUND: Functional decline is common in nursing home residents. Nursing staff can help prevent this decline, by encouraging residents to be more active in functional activities. Questionnaires measuring the extent to which nursing staff encourage functional activity among residents are lacking. In addition, there are no measurement instruments to gain insight into nursing staff perceived barriers and facilitators to this behavior. The aim of this study was to develop, and study the usability, of the MAastrIcht Nurses Activities INventory (MAINtAIN), an inventory assessing a) the extent to which nursing staff perceive to perform behaviors that optimize and maintain functional activity among nursing home residents and b) the perceived barriers and facilitators related to this behavior. METHODS: Using a mixed-methods approach the MAINtAIN was developed and its usability was studied. Development was based on literature, expert opinions, focus group (N = 3) and individual interviews (N = 14) with residents and staff from nine nursing homes in the Netherlands. Usability was studied in a cross-sectional study with 37 nurses and certified nurse assistants; data were analyzed using descriptive statistics. RESULTS: Development of the MAINtAIN resulted in two distinctive parts: MAINtAIN-behaviors and MAINtAIN-barriers. MAINtAIN-behaviors, targeting nursing staff behavior to optimize and maintain functional activity, includes 19 items covering activities of daily living, household activities, and miscellaneous activities. MAINtAIN-barriers addresses the perceived barriers and facilitators related to this behavior and comprises 33 items covering barriers and facilitators related to the residents, the professionals, the social context, and the organizational and economic context. The usability study showed that the inventory was not difficult to complete, that items and response options were clear, and that the number of missing values was low. Few items showed a floor or ceiling effect. CONCLUSIONS: The newly developed inventory MAINtAIN provides a usable method for researchers and nursing homes to obtain insight into nursing staff perceived behavior in optimizing functional activity among residents and their perceived barriers and facilitators related to this behavior. Outcomes of the MAINtAIN may contribute to change in nursing staff behavior and may improve nursing care. Further research with regard to the psychometric properties of the MAINtAIN is recommended.
BACKGROUND: Hospital mortality rate is a common measure of healthcare quality. Morbidity and mortality meetings are common but there are few reports of hospital-wide mortality-review processes to provide understanding of quality-of-care problems associated with patient deaths. OBJECTIVE: To describe the implementation and results from an institution-wide mortality-review process. DESIGN: A nurse and a physician independently reviewed every death that occurred at our multisite teaching institution over a 3-month period. Deaths judged by either reviewer to be unanticipated or to have any opportunity for improvement were reviewed by a multidisciplinary committee. We report characteristics of patients with unanticipated death or opportunity for improved care and summarise the opportunities for improved care. RESULTS: Over a 3-month period, we reviewed all 427 deaths in our hospital in detail; 33 deaths (7.7%) were deemed unanticipated and 100 (23.4%) were deemed to be associated with an opportunity for improvement. We identified 97 opportunities to improve care. The most common gap in care was: ‘goals of care not discussed or the discussion was inadequate’ (n=25 (25.8%)) and ‘delay or failure to achieve a timely diagnosis’ (n=8 (8.3%)). Patients who had opportunities for improvement had longer length of stay and a lower baseline predicted risk of death in hospital. Nurse and physician reviewers spent approximately 142 h reviewing cases outside of committee meetings. CONCLUSIONS: Our institution-wide mortality review found many quality gaps among decedents, in particular inadequate discussion of goals of care.
Emerging evidence indicates that harmful nursing home resident outcomes occur because of ineffective collaboration between registered nurses (RNs) and licensed practical nurses (LPNs) during assessment, care planning, delegation, and supervision. This observational, factorial vignette survey related video vignettes of RN–LPN collaboration in nursing home care to RN perceptions of: 1) current practice in their home; and 2) preferred practice in their home (N=444 rated vignettes of nursing practice). Current practice ranged from collaboration with few or poor-quality connections and a lack of differentiation between RN and LPN roles (low-capacity practice) to strong RN–LPN connections and clearly differentiated roles (high-capacity practice); RNs identified high-capacity practice as preferred. Interventions that bring together RNs and LPNs to learn new ways of giving care by differentiating roles while also strengthening connections show promise as levers for changing quality of care in nursing homes.
BACKGROUND: The conceptualisation and development of the role of Dementia Champions in clinical practice is ongoing, and dementia specific training has a significant impact on the scope of the role. AIM: This survey aimed to elicit Dementia Champions’ views on their role and associated training needs. METHODS: Data were collected via an online survey. FINDINGS: Of 188, 34 Dementia Champions (response rate 18%) participated. Most perceived dementia awareness training as useful, but limited. Areas suggested for further development were context specific skills training, education programmes that were formally recognised, and clarification around the expectations of the role. CONCLUSION: Expectations of ‘champion roles’ in dementia need to be re-visited, specifically in relation to the remit of the role and the level of education, preparation and support required for Dementia Champions to become change agents in dementia care.
Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: a quasi-experimental study
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BACKGROUND: There has been considerable publicity regarding population ageing and hospital emergency department (ED) overcrowding. Our study aims to investigate impact of one intervention piloted in Queensland Australia, the Hospital in the Nursing Home (HiNH) program, on reducing ED and hospital attendances from residential aged care facilities (RACFs). METHODS: A quasi-experimental study was conducted at an intervention hospital undertaking the program and a control hospital with normal practice. Routine Queensland health information system data were extracted for analysis. RESULTS: Significant reductions in the number of ED presentations per 1000 RACF beds (rate ratio (95 % CI): 0.78 (0.67-0.92); p = 0.002), number of hospital admissions per 1000 RACF beds (0.62 (0.50-0.76); p < 0.0001), and number of hospital admissions per 100 ED presentations (0.61 (0.43-0.85); p = 0.004) were noticed in the experimental hospital after the intervention; while there were no significant differences between intervention and control hospitals before the intervention. Pre-test and post-test comparison in the intervention hospital also presented significant decreases in ED presentation rate (0.75 (0.65-0.86); p < 0.0001) and hospital admission rate per RACF bed (0.66 (0.54-0.79); p < 0.0001), and a non-significant reduction in hospital admission rate per ED presentation (0.82 (0.61-1.11); p = 0.196). CONCLUSIONS: Hospital in the Nursing Home program could be effective in reducing ED presentations and hospital admissions from RACF residents. Implementation of the program across a variety of settings is preferred to fully assess the ongoing benefits for patients and any possible cost-savings.
BACKGROUND/RATIONALE: This report describes a quality improvement continuing medical education activity designed to enhance the recognition and treatment of residents with Alzheimer’s disease (AD) or other dementias in skilled-nursing facilities (SNFs). METHODS: Charts were compared in 6 areas prior to and following (stages A and C) a live, faculty-led workshop (stage B). Four SNFs completed stages A (n = 67 residents) and B, and 3 SNFs completed stage C (n = 52 residents). All charts came from residents with AD or a diagnosis of dementia or dementia-like symptoms. RESULTS/CONCLUSION: The SNFs had >95% baseline performance in both the frequency of cognitive assessments and documented medication reviews. The percentage of residents who received a quality-of-life assessment and those who had a mental health care plan in place represent areas for improvement. As part of this activity, a toolkit was developed to help guide facilities and clinicians in instituting care improvements for residents with AD/dementia.
BACKGROUND: To promote active daily living and improve the quality of life of older facility residents, it is important that care staff understand their day-to-day activities and needs. However, only a few studies have examined the needs of older residents and how care workers understand them. This study aimed to examine the subjective needs of older residents at aged care facilities, care workers’ understanding of these needs, and the gaps that exist between them. METHODS: Structured interviews with older residents with no severe cognitive impairment in ten Japanese aged care facilities and a questionnaire survey of care workers were conducted in 2008 regarding resident subjective needs. The questionnaire, which had satisfactory factorial validity, internal consistency, and reproducibility, consisted of seven items on basic activities of daily living (BADL), five items on instrumental ADL (IADL), eight items on environment and lifestyle (EL), and five items on emotion (EM). Pair-wise analyses were performed to compare responses. RESULTS: Responses of 115 pairs were analyzed (residents >/=75 years, 85 %; 21 men, 94 women). Median proportions of residents with IADL (66 %) and EL (69 %) needs were lower compared with those with BADL (83 %) and EM (91 %) needs. Median proportions of care workers understanding IADL (55 %) and EL (60 %) needs were lower compared with those understanding BADL (87 %) and EM (87 %) needs. Less than half of the care workers understood IADL needs for household chores (30 %) and money management (43 %), and an EL need for playing a role (41 %). CONCLUSIONS: Gaps were found between resident subjective needs and how care workers understood them. Specifically, care workers underestimated older residents’ IADL and EL needs, especially with regard to playing a role. These results highlight the need for care workers to set goals based on each resident’s subjective needs and plan strategies for care provision accordingly.
OBJECTIVE: Several barriers challenge resident engagement in learning quality improvement (QI). We investigated whether the incorporation of team-based game mechanics into an evidence-based online learning platform could increase resident participation in a QI curriculum. DESIGN: Randomized, controlled trial. SETTING: Tertiary-care medical center residency training programs. PARTICIPANTS: Resident physicians (n = 422) from nine training programs (anesthesia, emergency medicine, family medicine, internal medicine, ophthalmology, orthopedics, pediatrics, psychiatry and general surgery) randomly allocated to a team competition environment (n = 200) or the control group (n = 222). INTERVENTION: Specialty-based team assignment with leaderboards to foster competition, and alias assignment to de-identify individual participants. MAIN OUTCOME MEASURES: Participation in online learning, as measured by percentage of questions attempted (primary outcome) and additional secondary measures of engagement (i.e. response time). Changes in participation measures over time between groups were assessed with a repeated measures ANOVA framework. RESULTS: Residents in the intervention arm demonstrated greater participation than the control group. The percentage of questions attempted at least once was greater in the competition group (79% [SD +/- 32] versus control, 68% [SD +/- 37], P= 0.03). Median response time was faster in the competition group (P= 0.006). Differences in participation continued to increase over the duration of the intervention, as measured by average response time and cumulative percent of questions attempted (each P< 0.001). CONCLUSIONS: Team competition increases resident participation in an online course delivering QI content. Medical educators should consider game mechanics to optimize participation when designing learning experiences.
As the ethnic diversity of the U.S. population increases, there is a growing awareness of healthcare disparities and the need to address them. This position statement that the American Geriatrics Society (AGS) Ethnogeriatrics Committee developed outlines healthcare disparities in the United States and the minimum quality indicators that healthcare organizations and healthcare providers should adopt to ensure that all older adults receive care that is culturally appropriate and takes into account level of health literacy.
Quality improvement (QI) efforts affect a broader range of people than we often assume. These are the potential stakeholders for QI and its evaluation, and they have valuable perspectives to offer when they are consulted in planning, conducting and interpreting evaluations. QI practitioners are accustomed to consulting stakeholders to assess unintended consequences or assess patient experiences of care, but in many cases there are additional benefits to a broad inclusion of stakeholders. These benefits are better adherence to ethical standards, to assure that all legitimate interests take part, more useful and relevant evaluation information and better political buy-in to improve impact. Balancing various stakeholder needs for information requires skill for both politics and research management. These challenges have few pat answers, but several preferred practices, which are illustrated with practical examples.
OBJECTIVES: This study investigates the relationship between prices and quality of 7400 German nursing homes. METHOD: We use a cross section of public quality reports for all German nursing homes, which had been evaluated between 2010 and 2013 by external institutions. Our analysis is based on multivariate regressions in a two stage least squares framework, where we instrument prices to explain their effect on quality controlling for income, nursing home density, demographics, labour market characteristics, and infrastructure at the regional level. RESULTS: Descriptive analysis shows that prices and quality do not only vary across nursing homes, but also across counties and federal states and that quality and prices correlate positively. Second, the econometric analysis, which accounts for the endogenous relation between negotiated price and reported quality, shows that quality indeed positively depends on prices. In addition, more places in nursing homes per people in need are correlated with both lower prices and higher quality. Finally, unobserved factors at the federal state level capture some of the variation of reported quality across nursing homes. CONCLUSION: Our results suggest that higher prices increase quality. Furthermore, since reported quality and prices vary substantially across federal states, we conclude that the quality and prices of long-term care facilities may well be compared within federal states but not across.
BACKGROUND: Older people with mental health problems who meet needs based criteria for National Health Service (NHS) continuing care funding may be cared for in a variety of settings. These services have evolved due to socio-economic and political pressure, with the extent of movement of care from traditional NHS run long stay units into the private sector being unclear. Little attention has been paid to the best model of service provision for this group in terms of quality of care, patient outcomes, and cost effectiveness. METHODS: A literature review was conducted in order to explore what is known about service models for long-term psychiatric care for older people and their cost effectiveness. Following this review, an online survey was conducted in order to establish current specialist continuing care service provision by provider organizations, as well as any planned developments in services. RESULTS: The way specialist mental health continuing care services are provided in the United Kingdom (UK) varies, with just 45% (33) of NHS providers still operating their own services. Specialist mental health continuing care is an area of current service review for a number of organizations. CONCLUSIONS: Specialist care services for older adults with mental health problems in the UK are changing, but there is a lack of research on models of service delivery for this group of vulnerable individuals with complex needs. In the context of financial pressures within the NHS, and an increasing awareness of the need to develop and improve quality of services both for those with dementia and other mental illnesses, an urgent need for further research in this area is identified.
BACKGROUND: The positive deviance approach focuses on those who demonstrate exceptional performance, despite facing the same constraints as others. ‘Positive deviants’ are identified and hypotheses about how they succeed are generated. These hypotheses are tested and then disseminated within the wider community. The positive deviance approach is being increasingly applied within healthcare organisations, although limited guidance exists and different methods, of varying quality, are used. This paper systematically reviews healthcare applications of the positive deviance approach to explore how positive deviance is defined, the quality of existing applications and the methods used within them, including the extent to which staff and patients are involved. METHODS: Peer-reviewed articles, published prior to September 2014, reporting empirical research on the use of the positive deviance approach within healthcare, were identified from seven electronic databases. A previously defined four-stage process for positive deviance in healthcare was used as the basis for data extraction. Quality assessments were conducted using a validated tool, and a narrative synthesis approach was followed. RESULTS: 37 of 818 articles met the inclusion criteria. The positive deviance approach was most frequently applied within North America, in secondary care, and to address healthcare-associated infections. Research predominantly identified positive deviants and generated hypotheses about how they succeeded. The approach and processes followed were poorly defined. Research quality was low, articles lacked detail and comparison groups were rarely included. Applications of positive deviance typically lacked staff and/or patient involvement, and the methods used often required extensive resources. CONCLUSION: Further research is required to develop high quality yet practical methods which involve staff and patients in all stages of the positive deviance approach. The efficacy and efficiency of positive deviance must be assessed and compared with other quality improvement approaches. PROSPERO REGISTRATION NUMBER: CRD42014009365.
BACKGROUND: This paper argues that the global health agenda tends to privilege short-term global interests at the expense of long-term capacity building within national and community health systems. The Health Systems Strengthening (HSS) movement needs to focus on developing the capacity of local organizations and the institutions that influence how such organizations interact with local and international stakeholders. DISCUSSION: While institutions can enable organizations, they too often apply requirements to follow paths that can stifle learning and development. Global health actors have recognized the importance of supporting local organizations in HSS activities. However, this recognition has yet to translate adequately into actual policies to influence funding and practice. While there is not a single approach to HSS that can be uniformly applied to all contexts, several messages emerge from the experience of successful health systems presented in this paper using case studies through a complex adaptive systems lens. Two key messages deserve special attention: the need for donors and recipient organizations to work as equal partners, and the need for strong and diffuse leadership in low-income countries. An increasingly dynamic and interdependent post-Millennium Development Goals (post-MDG) world requires new ways of working to improve global health, underpinned by a complex adaptive systems lens and approaches that build local organizational capacity.
Research Practice and Methodology
BACKGROUND: The need for systematic methods for reviewing evidence is continuously increasing. Evidence mapping is one emerging method. There are no authoritative recommendations for what constitutes an evidence map or what methods should be used, and anecdotal evidence suggests heterogeneity in both. Our objectives are to identify published evidence maps and to compare and contrast the presented definitions of evidence mapping, the domains used to classify data in evidence maps, and the form the evidence map takes. METHODS: We conducted a systematic review of publications that presented results with a process termed “evidence mapping” or included a figure called an “evidence map.” We identified publications from searches of ten databases through 8/21/2015, reference mining, and consulting topic experts. We abstracted the research question, the unit of analysis, the search methods and search period covered, and the country of origin. Data were narratively synthesized. RESULTS: Thirty-nine publications met inclusion criteria. Published evidence maps varied in their definition and the form of the evidence map. Of the 31 definitions provided, 67 % described the purpose as identification of gaps and 58 % referenced a stakeholder engagement process or user-friendly product. All evidence maps explicitly used a systematic approach to evidence synthesis. Twenty-six publications referred to a figure or table explicitly called an “evidence map,” eight referred to an online database as the evidence map, and five stated they used a mapping methodology but did not present a visual depiction of the evidence. CONCLUSIONS: The principal conclusion of our evaluation of studies that call themselves “evidence maps” is that the implied definition of what constitutes an evidence map is a systematic search of a broad field to identify gaps in knowledge and/or future research needs that presents results in a user-friendly format, often a visual figure or graph, or a searchable database. Foundational work is needed to better standardize the methods and products of an evidence map so that researchers and policymakers will know what to expect of this new type of evidence review. SYSTEMATIC REVIEW REGISTRATION: Although an a priori protocol was developed, no registration was completed; this review did not fit the PROSPERO format.
BACKGROUND: Scoping reviews are used to identify knowledge gaps, set research agendas, and identify implications for decision-making. The conduct and reporting of scoping reviews is inconsistent in the literature. We conducted a scoping review to identify: papers that utilized and/or described scoping review methods; guidelines for reporting scoping reviews; and studies that assessed the quality of reporting of scoping reviews. METHODS: We searched nine electronic databases for published and unpublished literature scoping review papers, scoping review methodology, and reporting guidance for scoping reviews. Two independent reviewers screened citations for inclusion. Data abstraction was performed by one reviewer and verified by a second reviewer. Quantitative (e.g. frequencies of methods) and qualitative (i.e. content analysis of the methods) syntheses were conducted. RESULTS: After searching 1525 citations and 874 full-text papers, 516 articles were included, of which 494 were scoping reviews. The 494 scoping reviews were disseminated between 1999 and 2014, with 45 % published after 2012. Most of the scoping reviews were conducted in North America (53 %) or Europe (38 %), and reported a public source of funding (64 %). The number of studies included in the scoping reviews ranged from 1 to 2600 (mean of 118). Using the Joanna Briggs Institute methodology guidance for scoping reviews, only 13 % of the scoping reviews reported the use of a protocol, 36 % used two reviewers for selecting citations for inclusion, 29 % used two reviewers for full-text screening, 30 % used two reviewers for data charting, and 43 % used a pre-defined charting form. In most cases, the results of the scoping review were used to identify evidence gaps (85 %), provide recommendations for future research (84 %), or identify strengths and limitations (69 %). We did not identify any guidelines for reporting scoping reviews or studies that assessed the quality of scoping review reporting. CONCLUSION: The number of scoping reviews conducted per year has steadily increased since 2012. Scoping reviews are used to inform research agendas and identify implications for policy or practice. As such, improvements in reporting and conduct are imperative. Further research on scoping review methodology is warranted, and in particular, there is need for a guideline to standardize reporting.
To investigate the biomedical scientist’s perception of the prevailing publication culture.Design Qualitative focus group interview study.Setting Four university medical centres in the Netherlands.Participants Three randomly selected groups of biomedical scientists (PhD, postdoctoral staff members and full professors).Main outcome measures Main themes for discussion were selected by participants.Results Frequently perceived detrimental effects of contemporary publication culture were the strong focus on citation measures (like the Journal Impact Factor and the H-index), gift and ghost authorships and the order of authors, the peer review process, competition, the funding system and publication bias. These themes were generally associated with detrimental and undesirable effects on publication practices and on the validity of reported results. Furthermore, senior scientists tended to display a more cynical perception of the publication culture than their junior colleagues. However, even among the PhD students and the postdoctoral fellows, the sentiment was quite negative. Positive perceptions of specific features of contemporary scientific and publication culture were rare.Conclusions Our findings suggest that the current publication culture leads to negative sentiments, counterproductive stress levels and, most importantly, to questionable research practices among junior and senior biomedical scientists.
Quality improvement initiatives can become bogged down by excessive data collection. Sometimes the question arises—are we doing an adequate job with respect to a recommended practice? Are we complying with some guideline in at least X% of our patients? The perception that one must audit large numbers of charts may present a barrier to initiating local improvement activities. The model for improvement and its Plan–Do–Study–Act (PDSA) cycles typically require frequent data collection to test ideas and refine the planned change strategy. The perception that data collection must involve many patients can lead to insufficiently frequent PDSA cycles.1 In this review, we demonstrate the important contributions that small samples can make to improvement projects, including local audits, PDSA cycles and during broader implementation and evaluation.
BACKGROUND: Use of a total risk score (TRS) based on vascular and sociodemographic risk factors has been recommended to identify patients at risk of cognitive impairment. Moreover, combining screening tests has been reported to improve positive predictive values (PPV) for case finding of cognitive impairment. OBJECTIVE: We investigated the utility of the conjunctive combination of the informant-based AD8 and the performance-based National Institute of Neurological Disorders and Stroke-Canadian Stroke Network (NINDS-CSN) 5-minute protocol for the detection of cognitive impairment, defined by a clinical dementia rating (CDR) score >/=0.5, in patients at risk of cognitive impairment (TRS >/=3). METHODS: Participants were recruited from 2 primary healthcare centers in Singapore and received the AD8, Montreal Cognitive Assessment, Mini-Mental State Examination, CDR, and a formal neuropsychological test battery. The scores for NINDS-CSN 5-minute protocol were extracted from the Montreal Cognitive Assessment items. Area under the receiver operating characteristics curve analyses were conducted to determine the discriminant indices of the screening instruments, the conjunctive combination (ie, screened positive on both tests), and the compensatory combination (ie, screened positive in either of or both tests). RESULTS: A total of 309 participants were recruited of whom 78.7% (n = 243) had CDR = 0 and 21.3% (n = 66) had CDR >/=0.5. The conjunctive combination of AD8 and NINDS-CSN 5-minute protocol achieved excellent PPV and acceptable sensitivity (PPV 91.7%, sensitivity 73.3%). CONCLUSIONS: The conjunctive combination of the AD8 and NINDS-CSN 5-minute protocol is brief and accurate, and hence, suitable for case finding of cognitive impairment (CDR >/=0.5) in patients screened positive on the TRS in primary healthcare centers.
Quality of life and well-being of older patients in chronic care facilities is often determined by their relationships with nurses. The authors developed and tested a scale to assess patients’ views of what matters most when relating to nurses. Based on the humanistic nursing theory by Paterson and Zderad (1988), 69 items were created and tested with a sample of 40 patients, resulting in refinement of a scale with 24 items. This scale was factor analysed on responses from 249 patients residing in five facilities in Ontario, Canada. The Humanistic Relationship Importance Scale demonstrated strong internal consistency, stability, and reliability with a five-factor solution (α = .87). Construct validity was supported through factual identification. This scale is a valid measure of patients’ perspectives of a nurse-patient relationship in chronic care and can be used to measure health professionals’ relationships with their older patients and evaluate interventions to enhance relational care.
AIMS AND OBJECTIVES: To describe how the included items in three different scales, Downton Fall Risk Index, the short form of Mini Nutritional Assessment and the Modified Norton Scale are associated to severe outcomes as falls, weight loss and pressure ulcers. BACKGROUND: Falls, malnutrition and pressure ulcers are common adverse events among nursing home residents and risk scoring are common preventive activities, mainly focusing on single risks. In Sweden the three scales are routinely used together with the purpose to improve the quality of prevention. DESIGN: Longitudinal quantitative study. METHODS: Descriptive analyses and Cox regression analyses. RESULTS: Only 4% scored no risk for any of these serious events. Longitudinal risk scoring showed significant impaired mean scores indicating increased risks. This confirms the complexity of this population’s status of general condition. There were no statistical significant differences between residents categorised at risk or not regarding events. Physical activity increased falls, but decreased pressure ulcers. For weight loss, cognitive decline and the status of general health were most important. CONCLUSIONS: Risk tendencies for falls, malnutrition and pressure ulcers are high in nursing homes, and when measure them at the same time the majority will have several of these risks. Items assessing mobility or items affecting mobility were of most importance. Care processes can always be improved and this study can add to the topic. RELEVANCE TO CLINICAL PRACTICE: A more comprehensive view is needed and prevention can not only be based on total scores. Mobility is an important factor for falls and pressure ulcers, both as a risk factor and a protective factor. This involves a challenge for care – to keep the inmates physical active and at the same time prevent falls.
The effects of video observation of chewing during lunch on masticatory ability, food intake, cognition, activities of daily living, depression, and quality of life in older adults with dementia: a study protocol of an adjusted randomized controlled trial
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BACKGROUND: Masticatory functioning alters with age. However, mastication has been found to be related to, for example, cognitive functioning, food intake, and some aspects of activities of daily living. Since cognitive functioning and activities of daily living show a decline in older adults with dementia, improving masticatory functioning may be of relevance to them. A possible way to improve mastication may be showing videos of people who are chewing. Observing chewing movements may activate the mirror neuron system, which becomes also activated during the execution of that same movement. The primary hypothesis is that the observation of chewing has a beneficial effect on masticatory functioning, or, more specifically, masticatory ability of older adults with dementia. Secondary, the intervention is hypothesized to have beneficial effects on food intake, cognition, activities of daily living, depression, and quality of life. METHODS/DESIGN: An adjusted parallel randomized controlled trial is being performed in dining rooms of residential care settings. Older adults with dementia, for whom also additional eligibility criteria apply, are randomly assigned to the experimental (videos of chewing people) or control condition (videos of nature and buildings), by drawing folded pieces of paper. Participants who are able to watch each other’s videos are assigned to the same study condition. The intervention takes place during lunchtime, from Monday to Friday, for 3 months. During four moments of measurement, masticatory ability, food intake, cognitive functioning, activities of daily living, depression, and quality of life are assessed. Tests administrators blind to the group allocation administer the tests to participants. DISCUSSION: The goal of this study is to examine the effects of video observation of chewing on masticatory ability and several secondary outcome measures. In this study, the observation of chewing is added to the execution of the same action (i.e., during eating). Beneficial effects on masticatory ability, and consequently on the other outcome measures are hypothesized. The intervention may be easily integrated into daily care, and might add to the lives of the increasing number of older adults with dementia by beneficially influencing multiple daily life functions. TRIAL REGISTRATION: NTR5124 . Registration date: 30 March 2015.
BACKGROUND: Valid estimates of health-related quality-of-life (HRQoL) are often difficult to obtain from persons with Alzheimer’s disease (AD) and family caregiver proxies. To help assess whether the general public can serve as an alternate source of proxy HRQoL estimates in AD, we examined whether the general public can use vignettes to discriminate between AD health states. METHODS: We administered a telephone survey to randomly recruited participants from the general public who were aged 18 years or older. Interviewers read vignettes describing the mild, moderate, and severe AD health states to the participants, who answered the EQ-5D-5L and Quality of Life-Alzheimer’s Disease (QoL-AD) scales as if they had AD based on the vignette descriptions. Participants also answered the EQ-5D-5L for their current health states. We converted EQ-5D-5L responses into health utility scores using Canadian preference weights. We employed the Wilcoxon signed rank test to examine whether mean health utility scores and mean QoL-AD scores differed between health states. We used Pearson’s r to assess correlations between health utility and QoL-AD scores. RESULTS: Forty-eight participants (median age = 53 years; 25 female) completed the telephone interview; health utility and QoL-AD scores decreased as AD severity increased (p /= 0.62). CONCLUSIONS: Using the vignettes, the general public provided HRQoL estimates that discriminated between the three AD health states. This finding suggests the general public may be a promising source of proxy HRQoL estimates in place of persons with AD.
OBJECTIVE: This study examines the relationship between caregivers’ perception of community-based long-term care (CBLTC) services and the service use. METHOD: We used first two waves of the longitudinal data set of 1,416 dyads of care recipients and their caregivers in Singapore. Four perceived attributes of LTC services-service quality, convenience, social connectedness, and affordability-were measured on a 5-point scale. RESULTS: Among the four perceived attributes, perceived affordability was significantly associated with future utilization for all types of CBLTC services. Perceived service quality and convenience was significantly associated with center-based LTC services use. DISCUSSION: Caregivers are critically involved in the decision of using CBLTC services, and their perception of service characteristics is significantly associated with the uptake of CBLTC services. It is important to incorporate both care recipients’ and caregivers’ needs and preferences when designing and promoting integrated health care delivery models.
AIM: To develop and validate a scale that assesses quality of life in patients receiving home-based medical care. METHODS: A new quality of life scale was developed and evaluated in four phases: (i) item generation; (ii) first field study with a 14-item questionnaire; (iii) preliminary validation study, to reduce the number of items to four; and (iv) second field study comprising 40 patients, to evaluate the validity of the final version. Participants were requested to answer both the final version of the scale and the Short Form-8, to enable identification of any relationship between the two. RESULTS: Items were generated after discussions with doctors and care managers, and 14 items were selected for the draft version. In the preliminary validation study, 10 items were deleted, based on the results of statistical analysis of the data from the first field study. A psychometric analysis showed that the final four-item questionnaire had internal consistency (Cronbach’s alpha = 0.7), and a significant association with the Short Form-8. CONCLUSIONS: We created the first quality of life scale for patients receiving home-based medical care. The scale’s internal consistency was confirmed, as well as its external validity. This scale can be used independently of factors such as a patient’s age, sex, level of independence in the presence of dementia or disability, swallowing function, hearing ability and communication ability, and can be used with ease in routine clinical practice.
Effect of animal-assisted interventions on depression, agitation and quality of life in nursing home residents suffering from cognitive impairment or dementia: a cluster randomized controlled trial.
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OBJECTIVES: The prevalence of neuropsychiatric symptoms in cognitively impaired nursing home residents is known to be very high, with depression and agitation being the most common symptoms. The possible effects of a 12-week intervention with animal-assisted activities (AAA) in nursing homes were studied. The primary outcomes related to depression, agitation and quality of life (QoL). METHOD: A prospective, cluster randomized multicentre trial with a follow-up measurement 3 months after end of intervention was used. Inclusion criteria were men and women aged 65 years or older, with a diagnosis of dementia or having a cognitive deficit. Ten nursing homes were randomized to either AAA with a dog or a control group with treatment as usual. In total, 58 participants were recruited: 28 in the intervention group and 30 in the control group. The intervention consisted of a 30-min session with AAA twice weekly for 12 weeks in groups of three to six participants, led by a qualified dog handler. Norwegian versions of the Cornell Scale for Depression, the Brief Agitation Rating Scale and the Quality of Life in Late-stage Dementia scale were used. RESULTS: A significant effect on depression and QoL was found for participants with severe dementia at follow-up. For QoL, a significant effect of AAA was also found immediately after the intervention. No effects on agitation were found. CONCLUSIONS: Animal-assisted activities may have a positive effect on symptoms of depression and QoL in older people with dementia, especially those in a late stage.
Social integration has a significant influence on physical and mental health. Older adults experience an increased risk of social isolation as their social networks contract. The purpose of this study is to examine associations between dementia special care unit residents’ overall well-being and cognition with structural aspects of their coresident relationships. DESIGN AND METHODS: Measures of social network structure were calculated from self-reported social contact data within three cohorts of residents in one dementia special care unit. Pearson correlations were used to describe associations between overall quality of life and cognition, with network characteristics indicative of social integration. RESULTS: Approximately half the ties sent or received were reciprocated and positive associations were found between social integration and quality of life. However, inconsistent associations were found between social integration and cognitive function. Friendship ties were more frequent between people of adjacent cognitive status categories. In addition, comparing across personal networks, residents tended to be tied to residents of higher quality of life status (43.3%, n = 13 personal networks) as opposed to lower (30%, n = 9 networks) or same (26.7%, n = 8 networks). There is a strong positive correlation between quality of life and respondent’s betweenness centrality, suggesting that individuals with high quality of life tend to be important intermediaries between others in the community. IMPLICATIONS: Among the “oldest old,” quality of life and cognitive function are unevenly distributed, yet these health indicators tend to cluster in social networks. This reinforces that while quality of life may be highly individual, it is in part linked to relationships with others.
BACKGROUND: The prevalence of dementia is rising worldwide and many people will die with the disease. Symptoms towards the end of life may be inadequately managed and informal and professional carers poorly supported. There are few evidence-based interventions to improve end-of-life care in advanced dementia. AIM: To develop an integrated, whole systems, evidence-based intervention that is pragmatic and feasible to improve end-of-life care for people with advanced dementia and support those close to them. DESIGN: A realist-based approach in which qualitative and quantitative data assisted the development of statements. These were incorporated into the RAND/UCLA appropriateness method to achieve consensus on intervention components. Components were mapped to underlying theory of whole systems change and the intervention described in a detailed manual. SETTING/PARTICIPANTS: Data were collected from people with dementia, carers and health and social care professionals in England, from expert opinion and existing literature. Professional stakeholders in all four countries of the United Kingdom contributed to the RAND/UCLA appropriateness method process. RESULTS: A total of 29 statements were agreed and mapped to individual, group, organisational and economic/political levels of healthcare systems. The resulting main intervention components are as follows: (1) influencing local service organisation through facilitation of integrated multi-disciplinary care, (2) providing training and support for formal and informal carers and (3) influencing local healthcare commissioning and priorities of service providers. CONCLUSION: Use of in-depth data, consensus methods and theoretical understanding of the intervention components produced an evidence-based intervention for further testing in end-of-life care in advanced dementia.
In 2005, researchers from the Duke Center for Demographic Studies reported a “surprising trend”: data from the National Long-Term Care Surveys showed that the prevalence of severe cognitive impairment in the Medicare population had decreased significantly between 1982 and 1999. At a time when baby-boomer demographics led to predictions of a looming dementia crisis, this finding offered hope. Since that time, other reports have similarly shown that the incidence or prevalence of dementia is decreasing in various populations.
BACKGROUND: The diagnosis of dementia relies on the presence of new-onset cognitive impairment affecting an individual’s functioning and activities of daily living. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a questionnaire instrument, completed by a suitable ‘informant’ who knows the patient well, designed to assess change in functional performance secondary to cognitive change; it is used as a tool to identifying those who may have dementia.In secondary care there are two specific instances where patients may be assessed for the presence of dementia. These are in the general acute hospital setting, where opportunistic screening may be undertaken, or in specialist memory services where individuals have been referred due to perceived cognitive problems. To ensure an instrument is suitable for diagnostic use in these settings, its test accuracy must be established. OBJECTIVES: To determine the diagnostic accuracy of the informant-based questionnaire IQCODE, for detection of all-cause (undifferentiated) dementia in adults presenting to secondary-care services. SEARCH METHODS: We searched the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS Previews (Thomson Reuters Web of Science), Web of Science Core Collection (includes Conference Proceedings Citation Index) (Thomson Reuters Web of Science), CINAHL (EBSCOhost) and LILACS (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects – via the Cochrane Library); HTA Database (Health Technology Assessment Database via the Cochrane Library) and ARIF (Birmingham University). We also checked reference lists of relevant studies and reviews, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardised database subject headings such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA: We selected those studies performed in secondary-care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the ‘secondary care’ setting we included all studies which assessed patients in hospital (e.g. acute unscheduled admissions, referrals to specialist geriatric assessment services etc.) and those referred for specialist ‘memory’ assessment, typically in psychogeriatric services. DATA COLLECTION AND ANALYSIS: We screened all titles generated by electronic database searches, and reviewed abstracts of all potentially relevant studies. Two independent assessors checked full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reporting quality using the STARD tool. MAIN RESULTS: From 72 papers describing IQCODE test accuracy, we included 13 papers, representing data from 2745 individuals (n = 1413 (51%) with dementia). Pooled analysis of all studies using data presented closest to a cut-off of 3.3 indicated that sensitivity was 0.91 (95% CI 0.86 to 0.94); specificity 0.66 (95% CI 0.56 to 0.75); the positive likelihood ratio was 2.7 (95% CI 2.0 to 3.6) and the negative likelihood ratio was 0.14 (95% CI 0.09 to 0.22).There was a statistically significant difference in test accuracy between the general hospital setting and the specialist memory setting (P = 0.019), suggesting that IQCODE performs better in a ‘general’ setting.We found no significant differences in the test accuracy of the short (16-item) versus the 26-item IQCODE, or in the language of administration.There was significant heterogeneity in the included studies, including a highly varied prevalence of dementia (10.5% to 87.4%). Across the included papers there was substantial potential for bias, particularly around sampling of included participants and selection criteria, which may limit generalisability. There was also evidence of suboptimal reporting, particularly around disease severity and handling indeterminate results, which are important if considering use in clinical practice. AUTHORS’ CONCLUSIONS: The IQCODE can be used to identify older adults in the general hospital setting who are at risk of dementia and require specialist assessment; it is useful specifically for ruling out those without evidence of cognitive decline. The language of administration did not affect test accuracy, which supports the cross-cultural use of the tool. These findings are qualified by the significant heterogeneity, the potential for bias and suboptimal reporting found in the included studies.
Qualitative studies were synthesized to describe perspectives of people with dementia regarding meaningful activities. Themes of connectedness were identified using a meta-ethnography approach. The theme of being connected with self encompasses engagement for continuity, health promotion, and personal time. The theme of being connected with others includes being with others not to feel alone, doing an activity with others, and meaningful relationships. The theme of being connected with the environment encompasses being connected to one’s familiar environment, community, and nature. This synthesis suggests that connectedness is an important motivation for engagement in daily activities. Findings indicate that identifying the underlying motivation for an individual with dementia to engage in different activities is important for matching a person with activities that will be satisfying. This review may inform the development of interventions for engaging people with dementia in meaningful, daily activities and creating connectedness to self, others, and the environment.
OBJECTIVES: To identify distinct frailty trajectories (clusters of individuals following a similar progression of frailty over time) in an aging population and to estimate associations between frailty trajectories and emergency department visits, hospitalizations, and all-cause mortality. DESIGN: Population-based cohort study. SETTING: Olmsted County, Minnesota. PARTICIPANTS: Olmsted County, Minnesota residents aged 60-89 in 2005. MEASUREMENTS: Longitudinal changes in frailty between 2005 and 2012 were measured by constructing a yearly Rockwood frailty index incorporating body mass index, 17 comorbidities, and 14 activities of daily living. The frailty index measures variation in health status as the proportion of deficits present of the 32 considered (range 0-1). RESULTS: Of the 16,443 Olmsted County residents aged 60-89 in 2005, 12,270 (74.6%) had at least 3 years of frailty index measures and were retained for analysis. The median baseline frailty index increased with age (0.11 for 60-69, 0.14 for 70-79, 0.19 for 80-89). Three distinct frailty trajectories were identified in individuals aged 60-69 at baseline and two trajectories in those aged 70-79 and 80-89. Within each decade of age, increasing frailty trajectories were associated with greater risks of emergency department visits, hospitalization, and all-cause mortality, even after adjustment for baseline frailty index. CONCLUSION: The number of frailty trajectories differed according to age. Within each age group, those in the highest frailty trajectory had greater healthcare use and worse survival. Frailty trajectories may offer a way to target aging individuals at high risk of hospitalization or death for therapeutic or preventive interventions.
Government, health, social care and the third sector can work together to deliver high quality services to people living with dementia and their families. That’s what the new joint declaration by these bodies hopes to achieve. I’ve written recently on the NHS England blog about some of the challenges for finding medical treatments for dementia and its commonest causes. But what about care and support when someone actually has the condition?
Drawing on research in Ontario and overseas, the authors examine some promising community–based rural and urban initiatives. Through the lens of neo-institutional political theory, they analyze the hurdles encountered in attempting to scale up or replicate such initiatives. The authors say that in order to successfully meet the growing care needs of an aging population, governments will need to fulfill three essential conditions. First, instead of simply expanding the supply of residential long-term care beds, they should plan for “places” within a community-based care continuum, which includes supportive housing, attendant care, adult day programs and home care. Second, they should establish the conditions that enable promising community-care initiatives to be replicated or expanded. Third, they should channel funds based on patients’ needs, rather than on the location of care.
The purpose of this report is to analyze the clinical effectiveness and safety of antidepressants prescribed for the treatment of patients with dementia and co-morbid depression and in addition to describe any current certified clinical guidelines associated with their use.
A lecture by neuroscientist, Dr. Adrian Owen with panel discussion to follow.
Featured panelists include:
Dr. Adrian Owen, neuroscientist & Canada Excellence Research Chair in Cognitive Neuroscience and Imaging at Western University in London, Ontario
Dr. Jim Kutsogiannis, medical director in the Neurosciences ICU, University of Alberta Hospital
Dr. Wendy Johnston, neurology professor & medical director of the ALS clinic, University of Alberta
Dr. Brendan Leier, clinical ethicist, John Dossetor Health Ethics Centre, University of Alberta
Ron and Tracy Lucas, parents of an individual who is behaviourally unresponsive
1. To describe a parent driven research project
2. To highlight the role that social media can have in research on rare diseases
3. To discuss insights gained through this work
Looking for a tool to apply recommendations from a guidance document to your context? Have you identified a health system issue or problem? Are you looking to apply recommendations from a guidance document to address the issue/problem in your local context? Do you need to consider factors from the broader health system and political system in determining policy recommendations and decisions? The Contextualizing Guidance Workbook can help! How can the Contextualizing Guidance Workbook help you?
-Developed in concert with the World Health Organization, this tool is appropriate for use in any public health program area. -The Contextualizing Guidance Workbook outlines how to contextualize policy recommendations from research evidence for the development of local policy recommendations and decisions.
We will present on work we have been involved in with a National Center of Excellence in Knowledge Mobilization called Translating Emergency Knowledge for Kids (TREKK). TREKK addresses an identified gap between “what we know and what we do” in the context of pediatric emergency care, particularly in the context of general emergency departments. The vision of TREKK is that every child receives the highest standard of care, whether they are treated in a pediatric or general emergency department. We will give an overview of the goals and purpose of TREKK; discuss the results of a national needs assessment we conducted to identify information needs and priorities; and, present strategies we developed to mobilize knowledge to healthcare providers and parents, including use of knowledge pyramids, social media, and electronic tools. We will close with reflections on our experience to date including factors that have helped us achieve our goals.
This free 2-part workshop brings together the Residents’ Council President, Assistant, and the home Administrator to:
-Examine how each of their roles contribute to the effectiveness of Residents’ Council
-Explore effective tools, strategies and relevant legislation
-Discover skills and techniques to build a dynamic Residents’ Council that is meaningful and influential
-Learn how Residents’ Councils assist homes in aligning with legislative obligations including QIPs, compliance and resident centered care
Are you a researcher or someone who works in a policy or research setting? Are you asked questions about impact? Do you want to learn about impact measurement and how to tell your impact story to diverse audiences? The course curriculum, which was developed through international collaborations, is taught by national and international experts from leading health research and innovation organizations.
This ten week online statistics module is designed for health and social care professionals who want to understand the basics of analysis methods commonly used in medical research, in order to understand published research and to participate in more specialised courses. Students will learn to use and interpret basic statistical methods using SPSS, with reference to cohort studies, case control studies and randomized controlled trials. Online discussion forums enable communication between students and the tutor to provide support and to interpret and understand real-life scenarios.
Age matters when it comes to health costs, so some provinces want funding transfers to reflect that
Promise you won’t put me away. It is hard to say no to that request. But it often is even harder to honor it.
Everyone wants high-quality care. But how do patients, clinicians and administrators know what high-quality care looks like? Figuring this out can be surprisingly difficult.
First and foremost, never believe that having a co-author makes publishing easier. It can make it harder. Disagreements and style clashes must be resolved; idiosyncrasies and egos managed; distinct sets of preferences and prejudices satisfied. Even a single co-author seems to square the difficulty of getting the work finished.
Narratives from patients about their health care experiences can provide a valuable complement to standardized survey scores, both to help clinicians understand what they can do to improve their care and to engage and inform patients about differences among providers.
The advocacy organization Dying With Dignity believes that new laws currently being drafted by federal and provincial legislators and guidelines being formulated by the bodies overseeing medical professionals should allow for people diagnosed with dementia to make a request for assisted death ahead of time.
Collecting data for measurement can be like driving while looking in the rearview mirror. Improvement teams generally look at retrospective measurement data to understand performance, but rarely do they look at today’s data. Data for monitoring, on the other hand, helps us understand the risks and threats right in front of us. IHI Vice President Carol Haraden explains the difference between real-time data for monitoring and retrospective measurement data for understanding trends and improvement — both of which are critical for improving patient safety.
I’ve been an NHS doctor since 1989 and have devoted my career to the care of older people with frailty and long-term conditions – generally those presenting with acute illness or injury who require not just an immediate response but ongoing, proactive and joined-up care that crosses professional and organisational boundaries.
Those who work to provide in-home care for Aboriginal elders say the issues with CDC start with a fundamental problem: there simply are not many Aboriginal people working in the system.
Nurses aides and orderlies report injuries at a rate four times higher than the B.C. average
Scientists have detected a number of drugs which could help protect against Alzheimer’s disease, acting like statins for the brain.
In 2014, roughly 3.4 million Canadians aged 12 and older (11.2%) reported that they did not receive health care when they felt they needed it. Overall, females (12.4%) were more likely than males (10.0%) to have reported an unmet health care need. Among age groups, unmet health care needs were lowest for those aged 12 to 19 and those aged 65 or older, and were highest for those aged 20 to 54.
The newly released Silver Spaces™ app is a simple mobile application for seniors, families, health professionals, remodelers, builders, service providers and those who care about and for seniors. Safety and security in the home becomes a valid concern as the population ages and this app offers a room by room checklist, both interior and exterior, that defines what changes could be made to make it more resident-friendly.
The AHRQ Primary Care Practice Facilitation (PCPF) Curriculum is a new resource designed to help train practice facilitators, also called practice coaches, quality improvement coaches, or practice enhancement assistants on how to take an evidence-based approach to quality improvement in primary care practices. This is the latest addition to the portfolio of AHRQ products that support the growth of practice facilitation.
This toolkit has been designed to equip care homes with ideas and materials in order for them to provide a service focused on residents’ needs, preferences and activity choices. Throughout this toolkit, where it is recommended that specialist occupational therapy advice is required, this text will be highlighted in green. It will also link to the College of Occupational Therapists’ website, where there are many resources and further information. The guide for residents, their family and friends offers advice on best practice in terms of residents’ rights to engage in daily activities that support their health and wellbeing.
The role of the College Chair is to ensure that the peer review system supports the selection of the most innovative and cutting-edge proposals for research and knowledge translation, while continuing to be fair, well-managed and transparent. College Chairs will:
-provide strategic guidance in the building of the College as an internationally recognized resource, including:
-providing direction in defining and overseeing the College’s action plan to enhance peer review quality
-guiding continuous improvement across all College functions in support of peer review excellence
-oversee College recruitment strategies and implementation plans, including attracting potential members to the College
-ensure that frameworks, policies and activities relevant to learning, mentoring, recognition, membership and performance management are designed to enhance peer review quality and to retain strong reviewers
College Chairs will fulfill this leadership advisory role through the CIHR Chief Scientific Officer.
ICES is currently seeking two research program managers to join the ICES Research and Analysis team.
The research program manager, together with the scientific program lead, and the program coordinator, shares responsibility for the effective and efficient management of an internal research program. The research program manager provides direct oversight to a team of research analysts, epidemiologists, research project managers, research assistants and research administrative assistants in the program, including process mentorship and project allocation. The research program manager contributes his/her expertise to support ICES staff and ICES projects. In addition, the research program manager contributes to the ICES knowledge base and standards of practice in matters related to data, analysis, project management and research methodology.
ICES is currently seeking two research methodologists to join the ICES Research and Analysis team. The research methodologist assumes the role of in-house expert in various ICES datasets and statistical and computational methods. Collectively the research methodologists are tasked with developing the necessary tools and materials to undertake complex analyses as well as educating other analysts and promoting use of these techniques. Methodologists will disseminate their knowledge throughout the ICES research community. Collectively, the methodologists are responsible for the quality of analytic work performed by ICES research analytic staff. This position is considered an ICES-wide resource and does not reside within a particular research program.
Reporting to the Director, Measurement, Evaluation and Learning, under the leadership of OTF’s Knowledge Management Officer, your role will be essential in helping us cultivate digital relationships and foster knowledge sharing through content creation and online engagement.
KEY AREA OF RESPONSIBILITY:
-Researching, reviewing, developing, contributing to and/or writing content for primary distribution on OTF’s online Knowledge Centre.
-Working with OTF’s Strategy Leads as key Subject Matter Experts to capture and share key learnings in OTF’s Action Areas.
-Supporting the general uptake of knowledge assets by increasing engagement in OTF’s online Knowledge Centre, including contributing to and moderating forums, and guiding others who are new to online community building.