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New TREC Newsletter
March Newsletter
Read the latest newsletter from TREC for March 2017
Canadian Foundation for Healthcare Improvement (CFHI)
March 2017 Newsletter
Read the latest newsletter from CFHI.
New article by Dr. Jo Rycroft-Malone
Standards for Reporting Implementation Studies (StaRI) Statement
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Implementation studies are often poorly reported and indexed, reducing their potential to inform initiatives to improve healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aimed to develop guidelines for transparent and accurate reporting of implementation studies. Informed by the findings of a systematic review and a consensus-building e-Delphi exercise, an international working group of implementation science experts discussed and agreed the StaRI Checklist comprising 27 items. It prompts researchers to describe both the implementation strategy (techniques used to promote implementation of an underused evidence-based intervention) and the effectiveness of the intervention that was being implemented. An accompanying Explanation and Elaboration document (published in BMJ Open, doi:10.1136/bmjopen-2016-013318) details each of the items, explains the rationale, and provides examples of good reporting practice. Adoption of StaRI will improve the reporting of implementation studies, potentially facilitating translation of research into practice and improving the health of individuals and populations.
Calls for Abstracts
CALL FOR ABSTRACTS: Abstract Submission Deadline Extended
KT Canada Summer Institute
We are pleased to announce the Knowledge Translation (KT) Canada Summer Institute to be held in Toronto from June 26-28, 2017. The purpose of this Summer Institute is to provide participants with the opportunity to increase their understanding of knowledge translation research as well as opportunities and challenges in this field. The Summer Institute will provide participants with the chance to network with colleagues including national and international KT experts. The theme of the 2017 Institute is: “Patient oriented research”.
CALL FOR ABSTRACTS: Cochrane Canada Symposium 11-12 May, Hamilton ON
Cochrane Canada Symposium 2017: Evidence & Impact
Cochrane Canada invites you to submit abstracts for posters, oral presentations and workshops starting 15 February 2017. We welcome abstracts that reflect our mission: To promote evidence informed health decision making by producing high quality, relevant, accessible systematic reviews and other synthesized research evidence. We look forward to receiving abstracts on a variety of topics relevant to evidence producers and decision makers, including: 1) New and innovative methods to produce systematic reviews and evidence syntheses. 2) Strategies to engage decision makers in the production and use of high priority, relevant and accessible evidence syntheses. 3) Strategies to promote the use of evidence by decision makers, including consumers, practitioners, researchers, policy makers and others.
Grants & Awards
A new source of sample grants – NCI Funded Grants in Implementation Science
The National Cancer Institute is now providing excerpts of funded dissemination and implementation (D&I) grant applications online for educational purposes.
Michael Smith Foundation for Health Research: Reach Awards
As part of MSFHR’s commitment to facilitate the uptake and implementation of health research knowledge, we are excited to present the Reach Awards. New for 2017, these awards will provide funding to support the dissemination and uptake of research evidence to inform and improve further research, practice and policy-making. Each award will consist of up to $10,000 to help teams of health researchers and research users collaboratively plan and implement dissemination activities, adapting messages and mode of delivery in order to reach audiences who can directly use the information. Applications are due to open in the first week of April, 2017.
AB SPOR KT Platform Travel Award
The AB SPOR SUPPORT KT Platform will support up to two (2) graduate students and two (2) faculty members (for a total of four (4) awards) who will be attending the Cochrane Canada Symposium for the purpose of expanding their understanding of knowledge translation and/or knowledge synthesis. Each of the 4 award amounts will vary to a maximum of $1,200. For more information, please contact Morgan Potter, SPOR KT Training Coordinator at mrwagner@ualberta.ca
Publications
KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Practice and Methodology
Aging
KT
Does access to a demand-led evidence briefing service improve uptake and use of research evidence by health service commissioners? A controlled before and after study
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BACKGROUND: The Health and Social Care Act mandated research use as a core consideration of health service commissioning arrangements in England. We undertook a controlled before and after study to evaluate whether access to a demand-led evidence briefing service improved the use of research evidence by commissioners compared with less intensive and less targeted alternatives. METHODS: Nine Clinical Commissioning Groups (CCGs) in the North of England received one of three interventions: (A) access to an evidence briefing service; (B) contact plus an unsolicited push of non-tailored evidence; or (C) unsolicited push of non-tailored evidence. Data for the primary outcome measure were collected at baseline and 12 months using a survey instrument devised to assess an organisations’ ability to acquire, assess, adapt and apply research evidence to support decision-making. Documentary and observational evidence of the use of the outputs of the service were sought. RESULTS: Over the course of the study, the service addressed 24 topics raised by participating CCGs. At 12 months, the evidence briefing service was not associated with increases in CCG capacity to acquire, assess, adapt and apply research evidence to support decision-making, individual intentions to use research findings or perceptions of CCG relationships with researchers. Regardless of intervention received, participating CCGs indicated that they remained inconsistent in their research-seeking behaviours and in their capacity to acquire research. The informal nature of decision-making processes meant that there was little traceability of the use of evidence. Low baseline and follow-up response rates and missing data limit the reliability of the findings. CONCLUSIONS: Access to a demand-led evidence briefing service did not improve the uptake and use of research evidence by NHS commissioners compared with less intensive and less targeted alternatives. Commissioners appear well intentioned but ad hoc users of research. Further research is required on the effects of interventions and strategies to build individual and organisational capacity to use research.
Narrative review of frameworks for translating research evidence into policy and practice 
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BACKGROUND: A significant challenge in research translation is that interested parties interpret and apply the associated terms and conceptual frameworks in different ways. The purpose of this review was to: a) examine different research translation frameworks; b) examine the similarities and differences between the frameworks; and c) identify key strengths and weaknesses of the models when they are applied in practice. METHODS: The review involved a keyword search of PubMed. The search string was (translational research OR knowledge translation OR evidence to practice) AND (framework OR model OR theory) AND (public health OR health promotion OR medicine). Included studies were published in English between January 1990 and December 2014, and described frameworks, models or theories associated with research translation. RESULTS: The final review included 98 papers, and 41 different frameworks and models were identified. The most frequently applied knowledge translation framework in the literature was RE-AIM, followed by the knowledge translation continuum or ‘T’ models, the Knowledge to Action framework, the PARiHS framework, evidence based public health models, and the stages of research and evaluation model. CONCLUSION: The models identified in this review stem from different fields, including implementation science, basic and medical sciences, health services research and public health, and propose different but related pathways to closing the research-practice gap.
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Health Care Administration and Organization
‘Powerlessness’ or ‘doing the right thing’ – Moral distress among nursing home staff caring for residents at the end of life: An interpretive descriptive study
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Background:Caring for dying people can contribute to moral distress experienced by healthcare professionals. Moral distress can occur when this caring is restricted by organisational processes, resources or the provision of futile care. These factors apply to end of life care in nursing homes but research is lacking.Aim:To describe how nursing home staff experience moral distress when caring for residents during and at the end of life.Methods:An interpretive descriptive design, using the critical incident technique in semi-structured interviews to collect data from nursing home staff. Data were analysed using a thematic analysis approach.Setting:Four nursing homes in one large metropolitan area.Participants:A total of 16 staff: 2 nurse managers, 4 nurses and 10 care assistants.Findings:Participants described holding ?good dying? values which influenced their practice. The four practice-orientated themes of advocating, caring, communicating and relating with residents were found to influence interactions with residents, relatives, general practitioners, and colleagues. These led staff to be able to ?do the right thing? or to experience ?powerlessness?, which could in turn lead to staff perceiving a ?bad death? for residents.Conclusion:When there are incongruent values concerning care between staff and others involved in the care of residents, staff feel powerless to ?do the right thing? and unable to influence care decisions in order to avoid a ?bad death?. This powerlessness is the nature of their moral distress.; Background:Caring for dying people can contribute to moral distress experienced by healthcare professionals. Moral distress can occur when this caring is restricted by organisational processes, resources or the provision of futile care. These factors apply to end of life care in nursing homes but research is lacking.Aim:To describe how nursing home staff experience moral distress when caring for residents during and at the end of life.Methods:An interpretive descriptive design, using the critical incident technique in semi-structured interviews to collect data from nursing home staff. Data were analysed using a thematic analysis approach.Setting:Four nursing homes in one large metropolitan area.Participants:A total of 16 staff: 2 nurse managers, 4 nurses and 10 care assistants.Findings:Participants described holding ?good dying? values which influenced their practice. The four practice-orientated themes of advocating, caring, communicating and relating with residents were found to influence interactions with residents, relatives, general practitioners, and colleagues. These led staff to be able to ?do the right thing? or to experience ?powerlessness?, which could in turn lead to staff perceiving a ?bad death? for residents.Conclusion:When there are incongruent values concerning care between staff and others involved in the care of residents, staff feel powerless to ?do the right thing? and unable to influence care decisions in order to avoid a ?bad death?. This powerlessness is the nature of their moral distress.
The role of unregulated care providers in managing heart failure patients in long-term care facilities
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AIMS AND OBJECTIVES: Heart failure is a complex syndrome in which abnormal heart function results in clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion. Heart failure is common among long-term care residents, and is associated with significant morbidity and acute care utilisation. Heart failure guidelines endorse standard therapies, yet long-term care residents are less likely to receive recommended treatments. The objective of this study is to understand the perceptions and potential role of unregulated care providers in contributing to better heart failure management among long-term care residents. DESIGN: Focus group interviews. METHODS: This qualitative study employed focus groups to explore perceptions from 24 unregulated care providers in three Ontario, Canada long-term care homes, about barriers to the optimal management of heart failure. RESULTS: Three overarching concepts emerged characterising unregulated care providers’ experiences in caring for residents with heart failure in long-term care: (1) the complexity of providing heart failure care in a long-term care setting, (2) striving for resident-centred decision making and (3) unregulated care providers role enactment nested within an interprofessional team in long-term care. These concepts reflect the complex interplay between individual unregulated care providers and residents, and heart failure-related, socio-cultural and organisational factors that influence heart failure care processes in the long-term care system. CONCLUSIONS: Optimising the management of heart failure in long-term care is contingent on greater engagement of unregulated care providers as active partners in the interprofessional care team. Interventions to improve heart failure management in long-term care must ensure that appropriate education is provided to all long-term care staff, including unregulated care providers, and in a manner that fosters greater and more effective interprofessional collaboration. RELEVANCE TO CLINICAL PRACTICE: Active and collaborative engagement unregulated care providers has the potential to improve the management of heart failure in long-term care residents.
The Content and Meaning of Administrative Work: A qualitative study of Nursing Practices
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AIM: To investigate the content and meaning of nurses’ administrative work. BACKGROUND: Nurses often report that administrative work keeps them away from bedside care. The content and meaning of this work remains insufficiently explored. DESIGN: Comparative case studies. METHOD: The investigation took place in 2014. It was based on 254 hours of observations and 27 interviews with nurses and staff in two contrasting units: intensive care and long term care. A time and motion study was also performed over a period of 96 hours. RESULTS: Documentation and Organizational Activities is composed of 6 categories; documenting the patient record, coordination, management of patient flow, transmission of information, reporting quality indicators, ordering supplies- stock management Equal amounts of time were spent on these activities in each case. Nurses did not express complaints about documentation in intensive care, whereas they reported feeling frustrated by it in long term care. These differences reflected the extent to which these activities could be integrated into nurses’ clinical work and this is in turn was related to several factors: staff ratios, informatics and relevance to nursing work. CONCLUSION: Documentation and Organizational Activities are a main component of care. The meaning nurses attribute to them is dependent on organizational context. These activities are often perceived as competing with bedside care, but this does not have to be the case. The challenge for managers is to fully integrate them into nursing practice. Results also suggest that nurses’ Documentation and Organizational Activities should be incorporated into informatics strategies.
Experiences of moral distress by privately hired companions in Ontario’s long-term care facilities
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Purpose The purpose of this study was to explore long-term residential care provided by people other than the facilities? employees. Privately hired paid ?companions? are effectively invisible in health services research and policy. This research was designed to address this significant gap. There is growing recognition that nursing staff in long-term care (LTC) residential facilities experience moral distress, a phenomenon in which one knows the ethically right action to take, but is systemically constrained from taking it. To date, there has been no discussion of the distressing experiences of companions in LTC facilities. The purpose of this paper is to explore companions? moral distress. Design/methodology/approach Data were collected using week-long rapid ethnographies in seven LTC facilities in Southern Ontario, Canada. A feminist political economy analytic framework was used in the research design and in the analysis of findings. Findings Despite the differences in their work tasks and employment conditions, structural barriers can cause moral distress for companions. This mirrors the impacts experienced by nurses that are highlighted in the literature. Though companions are hired in order to fill care gaps in the LTC system, they too struggle with the current system?s limitations. The hiring of private companions is not a sustainable or equitable solution to under-staffing and under-funding in Canada?s LTC facilities. Originality/value Recognizing moral distress and its impact on those providing LTC is critical in relation to supporting and protecting vulnerable and precarious care workers and ensuring high-quality care for Canadians in LTC.; Purpose The purpose of this study was to explore long-term residential care provided by people other than the facilities? employees. Privately hired paid ?companions? are effectively invisible in health services research and policy. This research was designed to address this significant gap. There is growing recognition that nursing staff in long-term care (LTC) residential facilities experience moral distress, a phenomenon in which one knows the ethically right action to take, but is systemically constrained from taking it. To date, there has been no discussion of the distressing experiences of companions in LTC facilities. The purpose of this paper is to explore companions? moral distress. Design/methodology/approach Data were collected using week-long rapid ethnographies in seven LTC facilities in Southern Ontario, Canada. A feminist political economy analytic framework was used in the research design and in the analysis of findings. Findings Despite the differences in their work tasks and employment conditions, structural barriers can cause moral distress for companions. This mirrors the impacts experienced by nurses that are highlighted in the literature. Though companions are hired in order to fill care gaps in the LTC system, they too struggle with the current system?s limitations. The hiring of private companions is not a sustainable or equitable solution to under-staffing and under-funding in Canada?s LTC facilities. Originality/value Recognizing moral distress and its impact on those providing LTC is critical in relation to supporting and protecting vulnerable and precarious care workers and ensuring high-quality care for Canadians in LTC.
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Health Care Innovation and Quality Assurance
PRagmatic trial Of Video Education in Nursing homes: The design and rationale for a pragmatic cluster randomized trial in the nursing home setting
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Background/Aims Nursing homes are complex healthcare systems serving an increasingly sick population. Nursing homes must engage patients in advance care planning, but do so inconsistently. Video decision support tools improved advance care planning in small randomized controlled trials. Pragmatic trials are increasingly employed in health services research, although not commonly in the nursing home setting to which they are well-suited. This report presents the design and rationale for a pragmatic cluster randomized controlled trial that evaluated the “real world” application of an Advance Care Planning Video Program in two large US nursing home healthcare systems. Methods PRagmatic trial Of Video Education in Nursing homes was conducted in 360 nursing homes (N = 119 intervention/N = 241 control) owned by two healthcare systems. Over an 18-month implementation period, intervention facilities were instructed to offer the Advance Care Planning Video Program to all patients. Control facilities employed usual advance care planning practices. Patient characteristics and outcomes were ascertained from Medicare Claims, Minimum Data Set assessments, and facility electronic medical record data. Intervention adherence was measured using a Video Status Report embedded into electronic medical record systems. The primary outcome was the number of hospitalizations/person-day alive among long-stay patients with advanced dementia or cardiopulmonary disease. The rationale for the approaches to facility randomization and recruitment, intervention implementation, population selection, data acquisition, regulatory issues, and statistical analyses are discussed. Results The large number of well-characterized candidate facilities enabled several unique design features including stratification on historical hospitalization rates, randomization prior to recruitment, and 2:1 control to intervention facilities ratio. Strong endorsement from corporate leadership made randomization prior to recruitment feasible with 100% participation of facilities randomized to the intervention arm. Critical regulatory issues included minimal risk determination, waiver of informed consent, and determination that nursing home providers were not engaged in human subjects research. Intervention training and implementation were initiated on 5 January 2016 using corporate infrastructures for new program roll-out guided by standardized training elements designed by the research team. Video Status Reports in facilities’ electronic medical records permitted “real-time” adherence monitoring and corrective actions. The Centers for Medicare and Medicaid Services Virtual Research Data Center allowed for rapid outcomes ascertainment. Conclusion We must rigorously evaluate interventions to deliver more patient-focused care to an increasingly frail nursing home population. Video decision support is a practical approach to improve advance care planning. PRagmatic trial Of Video Education in Nursing homes has the potential to promote goal-directed care among millions of older Americans in nursing homes and establish a methodology for future pragmatic randomized controlled trials in this complex healthcare setting.
Initiative To Reduce Avoidable Hospitalizations Among Nursing Facility Residents Shows Promising Results
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Nursing facility residents are frequently admitted to the hospital, and these hospital stays are often potentially avoidable. Such hospitalizations are detrimental to patients and costly to Medicare and Medicaid. In 2012 the Centers for Medicare and Medicaid Services launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, using evidence-based clinical and educational interventions among long-stay residents in 143 facilities in seven states. In state-specific analyses, we estimated net reductions in 2015 of 2.2-9.3 percentage points in the probability of an all-cause hospitalization and 1.4-7.2 percentage points in the probability of a potentially avoidable hospitalization for participating facility residents, relative to comparison-group members. In that year, average per resident Medicare expenditures were reduced by $60-$2,248 for all-cause hospitalizations and by $98-$577 for potentially avoidable hospitalizations. The effects for over half of the outcomes in these analyses were significant. Variability in implementation and engagement across the nursing facilities and organizations that customized and implemented the initiative helps explain the variability in the estimated effects. Initiative models that included registered nurses or nurse practitioners who provided consistent clinical care for residents demonstrated higher staff engagement and more positive outcomes, compared to models providing only education or intermittent clinical care. These results provide promising evidence of an effective approach for reducing avoidable hospitalizations among nursing facility residents.
Implementation of ‘Goals of Patient Care’ medical treatment orders in residential aged care facilities: protocol for a randomised controlled trial
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INTRODUCTION: Systematic reviews demonstrate that advance care planning (ACP) has many positive effects for residents of aged care facilities, including decreased hospitalisation. The proposed Residential Aged Care Facility (RACF) ‘Goals of Patient Care’ (GOPC) form incorporates a resident’s prior advance care plan into medical treatment orders. Where none exists, it captures residents’ preferences. This documentation helps guide healthcare decisions made at times of acute clinical deterioration. METHODS AND ANALYSIS: This is a mixed methods study. An unblinded cluster randomised controlled trial is proposed in three pairs of RACFs. In the intervention arm, GOPC forms will be completed by a doctor incorporating advance care plans or wishes. In the control arm, residents will have usual care which may include an advance care plan. The primary hypothesis is that the GOPC form is superior to standard ACP alone and will lead to decreased hospitalisation due to clearer documentation of residents’ medical treatment plans. The primary outcome will be an analysis of the effect of the GOPC medical treatment orders on emergency department attendances and hospital admissions at 6 months. Secondary outcome measurements will include change in hospitalisation rates at 3 and 12 months, length of stay and external mortality rates among others. Qualitative interviews, 12 months post GOPC implementation, will be used for process evaluation of the GOPC and to evaluate staff perceptions of the form’s usefulness for improving communication and medical decision-making at a time of deterioration. DISSEMINATION: The results will be disseminated in peer review journals and research conferences. This robust randomised controlled trial will provide high-quality data about the influence of medical treatment orders that incorporate ACP or preferences adding to the current gap in knowledge and evidence in this area.
Exercise Interventions for Preventing Falls Among Older People in Care Facilities: A Meta-Analysis
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BACKGROUND: Falls in older people are a common problem, often leading to considerable morbidity. However, the overall effect of exercise interventions on fall prevention in care facilities remains controversial. AIMS: To evaluate the effectiveness of exercise interventions on the rate of falls and number of fallers in care facilities. METHODS: A meta-analysis was conducted of randomized controlled trials published up to December 2014. Eight databases were searched including Ovid-Medline, Embase, CINAHL, Cochrane Library, KoreaMed, KMbase, KISS, and KisTi. Two investigators independently extracted data and assessed study quality. RESULTS: Twenty-one studies were selected, that included 5,540 participants. Fifteen studies included exercise as a single intervention, whereas the remaining six included exercise combined with two or more fall interventions tailored to each resident’s fall risk (i.e., medication review, environmental modification or staff education). Meta-analysis showed that exercise had a preventive effect on the rate of falls (risk ratio [RR] 0.81, 95% CI 0.68-0.97). This effect was stronger when exercise combined with other fall interventions on the rate of falls (RR 0.61, 95% CI 0.52-0.72) and on the number of fallers (RR 0.85, 95% CI 0.77-0.95). Exercise interventions including balance training (i.e., gait, balance, and functional training; or balance and strength) resulted in reduced the rate of falls. Sensitivity analyses indicated that exercise interventions resulted in reduced numbers of recurrent fallers (RR 0.71, 95% CI 0.53-0.97). LINKING EVIDENCE TO ACTION: This review provides an important basis for developing evidence-based exercise intervention protocols for older people living in care facilities. Exercise programs, which are combined with tailored other fall interventions and challenge balance training to improve balance skills, should be applied to frail older people with functional limitations in institutional settings.
Implementation of the Veder contact method in daily nursing home care for people with dementia: a process analysis according to the RE-AIM framework
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AIMS AND OBJECTIVES: To perform a process analysis of the implementation of the Veder contact method for gaining insight into factors that influence successful implementation. BACKGROUND: Research showed that the original Veder method, which is a ‘living-room theatre performance’ provided by actors, positively influenced mood and quality of life of people with dementia. Training caregivers to execute such ‘performances’ and accomplish the same effects as actors proved difficult. However, key elements of the method were considered suitable for application in daily care, resulting in the development of a modified version of the method, named the Veder contact method. The Veder contact method combines elements from existing psychosocial interventions, e.g. reminiscence, validation and neuro-linguistic-programming with theatrical, poetic and musical communication, and applies this into daily care. DESIGN: For this process analysis a multiple case study design was used with the nursing home ward (n = 6) as the unit of analysis. METHODS: Eight focus groups with caregivers (n = 42) and 12 interviews with stakeholders were held. Using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework, a thematic analysis was conducted. RESULTS: The reach of the intervention (43-86%) and aspects of implementation-effectiveness (e.g. increased experienced reciprocity in contact with residents) facilitated implementation. For adoption and implementation, both facilitators (e.g. development of competences, feasibility of the Veder contact method without requiring extra time investment) and barriers (e.g. insufficient support of management, resistance of caregivers against the Veder contact method, organisational problems) were identified. Little effort was put into maintenance: only one nursing home developed a long-term implementation strategy. CONCLUSIONS: The Veder contact method can be applied in daily care without additional time investments. Although adopted by many caregivers, some were reluctant using the Veder contact method. Organisational factors (e.g. staffing and management changes, budget cuts) impeded long-term implementation. RELEVANCE TO CLINICAL PRACTICE: The findings from this study can be used for the development of successful implementation strategies for the Veder contact method and other person-centred care methods.
Increasing enjoyable activities to treat depression in nursing home residents with dementia: A pilot study
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This pilot study aimed to assess the feasibility and acceptability of a behavioral activities intervention (BE-ACTIV) in Australian nursing homes. BE-ACTIV was developed by researchers at the University of Louisville, USA, to improve mood and quality of life (QOL) in nursing home residents with mild to moderate dementia. An eight-week trial was conducted and 10 residents with mild to moderate dementia received the BE-ACTIV intervention while eight residents received a Walking and Talking intervention. Measures of depression (GDS-12R) and QOL (QOL-AD-NH) were administered prior to and following the interventions. Qualitative feedback indicated residents benefited from BE-ACTIV, evident by improved mood, although no statistically significant treatment effect was found. Moreover, the intervention was found to be feasible and acceptable to Australian nursing home staff and our findings highlight the importance of individualizing activities for people with dementia, of which 1:1 staff attention was a key component.
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Research Practice and Methodology
Intentional research design in implementation science: implications for the use of nomothetic and idiographic assessment
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The advancement of implementation science is dependent on identifying assessment strategies that can address implementation and clinical outcome variables in ways that are valid, relevant to stakeholders, and scalable. This paper presents a measurement agenda for implementation science that integrates the previously disparate assessment traditions of idiographic and nomothetic approaches. Although idiographic and nomothetic approaches are both used in implementation science, a review of the literature on this topic suggests that their selection can be indiscriminate, driven by convenience, and not explicitly tied to research study design. As a result, they are not typically combined deliberately or effectively. Thoughtful integration may simultaneously enhance both the rigor and relevance of assessments across multiple levels within health service systems. Background on nomothetic and idiographic assessment is provided as well as their potential to support research in implementation science. Drawing from an existing framework, seven structures (of various sequencing and weighting options) and five functions (Convergence, Complementarity, Expansion, Development, Sampling) for integrating conceptually distinct research methods are articulated as they apply to the deliberate, design-driven integration of nomothetic and idiographic assessment approaches. Specific examples and practical guidance are provided to inform research consistent with this framework. Selection and integration of idiographic and nomothetic assessments for implementation science research designs can be improved. The current paper argues for the deliberate application of a clear framework to improve the rigor and relevance of contemporary assessment strategies.
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Aging
How do we optimise care transition of frail older people?
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Demographic change continues to challenge health systems across the world, with older people accounting for the largest increase in hospital admissions. Older people often have multifactorial health and social care needs that contribute to longer hospital stays that then expose them to iatrogenic complications, including medication errors, falls, pressure ulcers and delirium, contributing further to functional decline. An added problem is an increase in risk of being re-hospitalised, with 15% of patients ≥65 years readmitted within 28 days. Each of these factors contribute to the importance of carefully coordinated discharge planning with supported hospital to home transitional care.
Comorbidity and polypharmacy in people with dementia: insights from a large, population-based cross-sectional analysis of primary care data
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Background: the care of older people with dementia is often complicated by physical comorbidity and polypharmacy, but the extent and patterns of these have not been well described. This paper reports analysis of these factors within a large, cross-sectional primary care data set. Methods: data were extracted for 291,169 people aged 65 years or older registered with 314 general practices in the UK, of whom 10,258 had an electronically recorded dementia diagnosis. Differences in the number and type of 32 physical conditions and the number of repeat prescriptions in those with and without dementia were examined. Age–gender standardised rates were used to calculate odds ratios (ORs) of physical comorbidity and polypharmacy. Results: people with dementia, after controlling for age and sex, had on average more physical conditions than controls (mean number of conditions 2.9 versus 2.4; P < 0.001) and were on more repeat medication (mean number of repeats 5.4 versus 4.2; P < 0.001). Those with dementia were more likely to have 5 or more physical conditions (age–sex standardised OR [sOR] 1.42, 95% confidence interval (CI) 1.35–1.50; P < 0.001) and were also more likely to be on 5 or more (sOR 1.46; 95% CI 1.40–1.52; P < 0.001) or 10 or more repeat prescriptions (sOR 2.01; 95% CI 1.90–2.12; P < 0.001). Conclusions: people with dementia have a higher burden of comorbid physical disease and polypharmacy than those without dementia, even after accounting for age and sex differences. Such complex needs require an integrated response from general health professionals and multidisciplinary dementia specialists.
Preferences for the emergency department or alternatives for older people in aged care: a discrete choice experiment
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Objectives to estimate the effect of factors that influence decisions to transfer residents of aged care facilities to an emergency department (ED) for acute medical emergencies. Design and participants a discrete choice experiment with residents (N = 149), the relatives of residents (N = 137) and staff members (N = 128) of aged care facilities. Setting aged care facilities in three Australian states. Outcome measures using random parameter logit models, parameter estimates and odds ratios were estimated, and resultant utility functions for ED and alternate care were constructed. Results all attributes (including waiting time, complication rates, symptom relief and time spent alone) significantly influence choice for accessing acute care. There is a strong overall preference for ED care (odds ratio 1.73, 95% confidence interval 1.57–1.92), but this varies by clinical scenario, being the strongest for pneumonia and weakest for wrist fracture. Relatives of residents were less tolerant of reductions in care quality than staff members or residents themselves. Conclusion underlying preference for ED transfer of aged care facility residents in acute medical emergencies is strong and independent of commonly used quality of care measures.
Effect of caregiving relationship and formal long-term care service use on caregiver well-being
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AIM: Despite efforts to revise the traditional long-term care (LTC) model, informal caregivers continue to provide a substantial amount of support to older adults as front-line care providers. The present study aimed to understand the effect of informal caregiving on caregivers’ well-being in Singapore with respect to different types of patient-caregiver relationships. Second, this study examined the association between formal LTC service use and caregivers’ well-being. METHODS: Two waves of data for 781 dyads of patients with LTC needs and their caregivers from a longitudinal study were analyzed. Multilevel regression models were used to examine the association between caregivers’ well-being (self-rated general health, stress level and quality of life) and LTC service use among different patient-caregiver relationships. RESULTS: Spousal caregivers reported significantly lower quality of life compared with adult children caregivers. Non-immediate family caregivers showed better overall well-being compared with spouse and adult children caregivers. Caregivers of patients referred to nursing homes reported higher levels of stress and poorer self-rated general health compared with caregivers of patients referred to community-based services. Spouse and non-immediate family caregivers of patients who utilized nursing home or home-based services presented poorer self-rated general health than caregivers of the patients who did not use any formal services. CONCLUSIONS: Developing a better understanding of the associations between well-being and formal LTC service use for different types of patient-caregiver relationships is critical for policy makers and healthcare providers who aim to create holistic systems of care.
Prevalence of inappropriate medication use in residential long-term care facilities for the elderly: A systematic review
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BACKGROUND: Multi-morbidity and polypharmacy of the elderly population enhances the probability of elderly in residential long-term care facilities experiencing inappropriate medication use. OBJECTIVES: The aim is to systematically review literature to assess the prevalence of inappropriate medication use in residential long-term care facilities for the elderly. METHODS: Databases (MEDLINE, EMBASE) were searched for literature from 2004 to 2016 to identify studies examining inappropriate medication use in residential long-term care facilities for the elderly. Studies were eligible when relying on Beers criteria, STOPP, START, PRISCUS list, ACOVE, BEDNURS or MAI instruments. Inappropriate medication use was defined by the criteria of these seven instruments. RESULTS: Twenty-one studies met inclusion criteria. Seventeen studies relied on a version of Beers criteria with prevalence ranging between 18.5% and 82.6% (median 46.5%) residents experiencing inappropriate medication use. A smaller range, from 21.3% to 63.0% (median 35.1%), was reported when considering solely the 10 studies that used Beers criteria updated in 2003. Prevalence varied from 23.7% to 79.8% (median 61.1%) in seven studies relying on STOPP. START and ACOVE were relied on in respectively four (prevalence: 30.5-74.0%) and two studies (prevalence: 28.9-58.0%); PRISCUS, BEDNURS and MAI were all used in one study each. CONCLUSIONS: Beers criteria of 2003 and STOPP were most frequently used to determine inappropriate medication use in residential long-term care facilities. Prevalence of inappropriate medication use strongly varied, despite similarities in research design and assessment with identical instrument(s).
Applying of Decision Tree Analysis to Risk Factors Associated with Pressure Ulcers in Long-Term Care Facilities
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OBJECTIVES: The purpose of this study was to use decision tree analysis to explore the factors associated with pressure ulcers (PUs) among elderly people admitted to Korean long-term care facilities. METHODS: The data were extracted from the 2014 National Inpatient Sample (NIS)-data of Health Insurance Review and Assessment Service (HIRA). A MapReduce-based program was implemented to join and filter 5 tables of the NIS. The outcome predicted by the decision tree model was the prevalence of PUs as defined by the Korean Standard Classification of Disease-7 (KCD-7; code L89*). Using R 3.3.1, a decision tree was generated with the finalized 15,856 cases and 830 variables. RESULTS: The decision tree displayed 15 subgroups with 8 variables showing 0.804 accuracy, 0.820 sensitivity, and 0.787 specificity. The most significant primary predictor of PUs was length of stay less than 0.5 day. Other predictors were the presence of an infectious wound dressing, followed by having diagnoses numbering less than 3.5 and the presence of a simple dressing. Among diagnoses, “injuries to the hip and thigh” was the top predictor ranking 5th overall. Total hospital cost exceeding 2,200,000 Korean won (US $2,000) rounded out the top 7. CONCLUSIONS: These results support previous studies that showed length of stay, comorbidity, and total hospital cost were associated with PUs. Moreover, wound dressings were commonly used to treat PUs. They also show that machine learning, such as a decision tree, could effectively predict PUs using big data.
Effectiveness of person-centered care on people with dementia: a systematic review and meta-analysis
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BACKGROUND: Person-centered care is a holistic and integrative approach designed to maintain well-being and quality of life for people with dementia, and it includes the elements of care, the individual, the carers, and the family. AIM: A systematic literature review and meta-analysis were undertaken to investigate the effectiveness of person-centered care for people with dementia. METHODS: Literature searches were undertaken using six databases including Medline, EMBASE, CINAHL, PsycINFO, Cochrane Database, and KoreaMed using the following keywords: cognition disorder, dementia, person-centered care, patient-centered care, client-centered care, relationship-centered care, and dementia care. The searches were limited to interventional studies written in English and Korean and included randomized controlled studies and noncontrolled studies for people with dementia living in any setting. RESULTS: Nineteen interventional studies, including 3,985 participants, were identified. Of these, 17 studies were from long-term care facilities and two studies were from homecare settings. The pooled data from randomized controlled studies favored person-centered care in reducing agitation, neuropsychiatric symptoms, and depression and improving the quality of life. Subgroup analysis identified greater effectiveness of person-centered care when implemented for people with less severe dementia. For agitation, short-term interventions had a greater effect (standardized mean difference [SMD]: -0.434; 95% conference interval [CI]: -0.701 to -0.166) than long-term interventions (SMD: -0.098; 95% CI: -0.190 to 0.007). Individualized activities resulted in a significantly greater beneficial effect than standard care (SMD: 0.513; 95% CI: -0.994 to -0.032). However, long-term, staff education, and cultural change interventions had a greater effect on improving the quality of life for people with dementia (SMD: 0.191; 95% CI: 0.079 to 0.302). CONCLUSION: This systematic review and meta-analysis provided evidence for person-centered care in clinical practice for people with dementia. Person-centered care interventions were shown to reduce agitation, neuropsychiatric symptoms, and depression and to improve the quality of life. Person-centered care interventions can effectively reduce agitation for a short term using intensive and activity-based intervention. However, an educational strategy that promotes learning and skill development of internal care staff is needed to enhance patient’s quality of life and to ensure the sustainability of the effects of behavioral problems. The feasibility and effectiveness of the intervention, the severity of patient disease, and intervention type and duration should be considered as part of an intervention design.
Proportion of dementia in Australia explained by common modifiable risk factors
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BACKGROUND: At present, dementia has no known cure. Interventions to delay onset and reduce prevalence of the disease are therefore focused on risk factor reduction. Previous population attributable risk estimates for western countries may have been underestimated as a result of the relatively low rates of midlife obesity and the lower weighting given to that variable in statistical models. METHODS: Levin’s Attributable Risk which assumes independence of risk factors was used to calculate the proportion of dementia attributable to seven modifiable risk factors (midlife obesity, physical inactivity, smoking, low educational attainment, diabetes mellitus, midlife hypertension and depression) in Australia. Using a recently published modified formula and survey data from the Australia Diabetes, Obesity and Lifestyle Study, a more realistic population attributable risk estimate which accounts for non-independence of risk factors was calculated. Finally, the effect of a 5-20% reduction in each risk factor per decade on future dementia prevalence was computed. RESULTS: Taking into consideration that risk factors do not operate independently, a more conservative estimate of 48.4% of dementia cases (117,294 of 242,500 cases) was found to be attributable to the seven modifiable lifestyle factors under study. We calculated that if each risk factor was to be reduced by 5%, 10%, 15% and 20% per decade, dementia prevalence would be reduced by between 1.6 and 7.2% in 2020, 3.3-14.9% in 2030, 4.9-22.8% in 2040 and 6.6-30.7% in 2050. CONCLUSION: Our largely theory-based findings suggest a strong case for greater investment in risk factor reduction programmes that target modifiable lifestyle factors, particularly increased engagement in physical activity. However, further data on risk factor treatment and dementia risk reduction from population-based studies are needed to investigate whether our estimates of potential dementia prevention are indeed realistic.
A systematic review of effectiveness of decision aids to assist older patients at the end of life
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OBJECTIVE: To describe the range of decision aids (DAs) available to enable informed choice for older patients at the end of life and assess their effectiveness or acceptability. METHODS: Search strategy covered PubMed, Scopus, Ovid MEDLINE, EMBASE, EBM Reviews, CINAHL and PsycInfo between 1995 and 2015. The quality criteria framework endorsed by the International Patient Decision Aids Standards (IPDAS) was used to assess usefulness. RESULTS: Seventeen DA interventions for patients, their surrogates or health professionals were included. Half the DAs were designed for self-administration and few described use of facilitators for decision-making. TREATMENT: options and associated harms and benefits, and patient preferences were most commonly included. Patient values, treatment goals, numeric disease-specific prognostic information and financial implications of decisions were generally not covered. DAs at the end of life are generally acceptable by users, and appear to increase knowledge and reduce decisional conflict but this effectiveness is mainly based on low-level evidence. CONCLUSIONS: Continuing evaluation of DAs in routine practice to support advance care planning is worth exploring further. In particular, this would be useful for conditions such as cancer, or situations such as major surgery where prognostic data is known, or in dementia where concordance on primary goals of care between surrogates and the treating team can be improved. PRACTICE IMPLICATIONS: Given the sensitivities of end-of-life, self-administered DAs are inappropriate in this context and genuine informed decision-making cannot happen while those gaps in the instruments remain.
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Events
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Canadian Frailty Network 2017 National Conference
Contribute to answering these questions and more at the Canadian Frailty Network (CFN) 2017 National Conference: Canada’s pre-eminent conference on frailty. Join April 23-24 in Toronto to hear from, share knowledge, brainstorm and network with leading experts in the field – addressing the full continuum of care, education/training and citizen engagement. In addition to presenting the latest knowledge – looking ahead to the next five years and beyond will be a focal point and recurring theme throughout the conference.
4th Biennial Society for Implementation Research Collaboration Conference [SIRC 2017]
Organizers for the 4th Biennial Society for Implementation Science Collaboration Conference are currently accepting abstracts. The theme for SIRC 2017 is “Implementation Mechanisms: What Makes Implementation Work and Why?”
The intended audience includes “all the players in the evidence based medicine ecosystem,” including: clinicians, medics, nurses, physios, OTs; researchers; journal editors, other journal staff and medical writers; patients, and carers; the public, as payers, and as civil society; policymakers, politicians and civil servants; professional bodies, medical and academic; the pharmaceutical, diagnostic, and device industries; health services, payers, the NHS, and insurance companies; healthcare administrators and managers; cost-effectiveness agencies, IQWiG, NICE, and more; regulators; students; registry owners; and others.
Finding and Using Research Evidence to Inform Decision-Making in Health Systems and Organizations
The McMaster Health Forum is offering a workshop on how to use research evidence to inform health system policy issues as part of the regular in-person training workshop series. Registration for the spring 2017 workshop closes April 7, 2017. The intended audience for the workshops include interested individual policymakers, stakeholders, and researchers. Each workshop consists of a combination of online instruction and five days of in-person workshop in Hamilton, Ontario, Canada.
Spring 2017 Systematic Review Workshop
The workshop is designed to teach clinicians, researchers and decision-makers how to plan, conduct and communicate the findings of a systematic review. The registration deadline is April 19, 2017. Because space is limited, registration is on a first-come, first-served basis.
Communicating Science: Tools for Disability and Rehabilitation Researchers
This workshop takes place on April 5 from 12:30-5:00 PM, at the Hilton Alexandria Old Town, Alexandria, VA. Emily Cloyd, Director of Public Engagement at the American Association for the Advancement of Science (AAAS), will lead an interactive workshop focusing on researcher involvement in public communication of science and how to connect with specific audiences. A special one-hour seminar will focus on strategic social media and online science communication.
The 39th Annual NARRTC Conference
NIDILRR grantees and other interested parties are invited to participate in Communicating Science: Tools for Disability and Rehabilitation Researchers. This is a half-day in-person workshop to be held on Wednesday, April 5, 2017 (12:30 PM – 5 PM) at the Hilton Alexandria Old Town, VA. (Day prior to the start of the NARRTC Conference). Presenters from the American Association for the Advancement of Science (AAAS) will lead an interactive session focusing on researcher involvement in public communication of science and how to connect with specific audiences. The workshop will close with a special one-hour session focusing on strategic social media and online science communication.
Cochrane Canada Symposium 2017: Evidence & Impact
The Symposium will be held at McMaster University’s David Braley Health Sciences Centre. We look forward to exploring this year’s theme – Evidence and Impact – with consumers, healthcare and public health practitioners, health program managers, health policy decision makers, systematic reviewers and other researchers, guideline developers, trainees, workplace wellness professionals and health research evidence end users.
Online
KT Connects: Knowledge Translation Webinar Series
The next webinar “Patients’ experiences of engaging in health research: Partners in the dance” features Sheila Kerr and Kelly English (Arthritis Patient Advisory Board, Arthritis Research Canada).
Spotlight on Methods and Tools: Knowledge Translation and Implementation Video Series
Do you plan program implementation? Are you interested in an overview of some of the key concepts involved in the implementation of evidence-based practices? Join the National Collaborating Centre for Methods and Tools (NCCMT) for a webinar about the Knowledge Translation and Implementation Video Series!
In this community-based study we assessed the implementation feasibility and impact of the ‘Frailty Portal’ in the identification, raising awareness of, care planning and delivery of appropriate care for the frail in community primary care practice. Primary Healthcare (PHC) providers regularly encounter frail persons in their daily clinical work. However, routine identification and measurement of frailty is not part of primary care standard practice and there is a general lack of awareness about, and consistency in approach to, frailty. The ‘Frailty Portal’ was developed to aid in the identification, screening and care planning for frail patients.
KTDRR’s 2017 Online KT Conference
NIDILRR grantees are highly concerned about measuring the outcomes and impact from their knowledge translation activities. This online conference is designed to address the planning and implementation of effective and efficient KT outcome measurement tools and approaches.
Tune-in to the last webinar of the season! Dr. Thomas Rotter, Research Chair in Health Quality Improvement Science at the University of Saskatchewan, and Dr. Donna Goodridge, Co-Chair of the Canadian Thoracic Society (CTS) COPD Clinical Assembly and a Professor at the University of Saskatchewan, will present our April Webinar with Dr. Shannon Scott, Professor and Canada Research Chair for Knowledge Translation in Child Health with the Faculty of Nursing at the University of Alberta.
Courses
Implementation Science Masterclass 2017
The Collaboration for Leadership in Applied Health Research and Care South London (CLAHRC South London) is hosting an Implementation Science Masterclass in July 2017. The Masterclass includes lectures, group work, and guidance to help participants work more effectively on implementation projects. Health professionals, researchers, patients and service users, policymakers, commissioners and managers and encouraged to attend.
Implementation – Theory and Application in Health Care
Applications for the 2017 postgraduate course “Implementation—Theory and Application in Healthcare” are now being accepted. The course provides a broad introduction to the development of implementation science and the research conducted in this field and meets three times during the fall: September 20-21, October 10-12, and November 30. Applications are due by April 30.
Online
UCSF Online Implementation Science Courses and Certificate Program
UCSF is now enrolling for their online Spring 2017 courses. The intended audience for the courses are: clinical/public health researchers, clinicians, public health/public policy practitioners, and quality improvement officers. The spring courses are “Framing Research to Influence Policy” and “Community Engaged Research”. Applications are due prior to the start of each course with a rolling deadline until all spots are filled. Spring courses begin on April 3, 2017.
News
The Canadian Foundation for Healthcare Improvement and Fraser Health announced that they are fast-tracking the regional spread of an innovative screening tool that reduced transfers to the emergency department (ED) from residential care by 71 percent. This rollout will establish the PREVIEW-ED© tool as standard practice in all 80 Fraser Health homes, reaching 8063 seniors, and will pave the way for the tool to be spread across Canada later in 2017.
Canadian Frailty Network: March 2017 Newsletter
Read the March Newsletter from the Canadian Frailty Network.
B.C. announces $500M plan to improve seniors’ care
British Columbia’s government will spend $500 million over the next four years to improve care for seniors, including increasing the direct services the elderly receive at residential care facilities.
Resources
No Place to Grow Old: How Canadian Suburbs Can Become Age Friendly
With Canada’s population aging rapidly, municipalities must refocus community planning efforts to deal with the impact of decades-old car-dependent suburban sprawl that leaves less mobile seniors isolated. Although most of Ontario’s largest cities have declared their intention to become “age-friendly,” none have yet taken the basic step of amending their land-use plans to reflect that commitment. Amending provincial planning policies to make age-friendly planning a municipal priority would complement other provincial policies favouring compact, walkable development and promoting aging at home.
Young-onset dementia: Understanding your diagnosis
This booklet is for anyone under the age of 65 who has recently been told they have dementia. It will help you understand more about dementia in people under 65 (‘young-onset dementia’) and the treatments, support and services that are available. It includes information about how you can live as well as possible with dementia and about making plans for the future.
Simon Fraser University: Reports and Publications
There are a number of reports and publications on long-term care homes and older adults.
Toolkit Designed To Reduce Urinary Tract Infections in Long-Term Care
The toolkit uses strategies from AHRQ’s Comprehensive Unit-based Safety Program (CUSP), which has reduced CAUTI as well as central line-associated bloodstream infections in hospitals. The toolkit is based on the experiences of more than 450 long-term care facilities nationwide and resulted in a significant reduction of CAUTI rates.
Opportunities
Associate/Full Professor, Implementation Science – University of Alabama College of Education
The University of Alabama College of Education is looking for an associate or full professor of implementation science. The position is in the special education department (SPEMA), but the person is expected to work across disciplines.
