May 14, 2019

Grants & Awards


New article by Carole Estabrooks and Stephanie Chamberlain dans Options Politiques et en français
L’extrême solitude des aînés sans proches et inaptes

Il faut mettre en place des mesures pour répondre aux besoins quotidiens essentiels des aînés sans proches et inaptes, et améliorer leur qualité de vie.

New article by Greta Cummings, Gillian Harvey, Alison Kitson, Lars Walling
From Research Evidence to “Evidence by Proxy”? Organizational Enactment of Evidence‐Based Health Care in Four High‐Income Countries
Non UofA Access

Roman Kislov, Paul Wilson, Greta Cummings, et al.
Public Admin Rev 2019 04/30; 2019/05;0(0)
Drawing on multiple qualitative case studies of evidence-based health care conducted in Sweden, Canada, Australia, and the United Kingdom, the authors systematically explore the composition, circulation, and role of codified knowledge deployed in the organizational enactment of evidence-based practice. The article describes the ?chain of codified knowledge,? which reflects the institutionalization of evidence-based practice as organizational business as usual, and shows that it is dominated by performance standards, policies and procedures, and locally collected (improvement and audit) data. These interconnected forms of “evidence by proxy,” which are informed by research partly or indirectly, enable simplification, selective reinforcement, and contextualization of scientific knowledge. The analysis reveals the dual effects of this codification dynamic on evidence-based practice and highlights the influence of macro-level ideological, historical, and technological factors on the composition and circulation of codified knowledge in the organizational enactment of evidence-based health care in different countries.

CIHR’s new Strategic Plan: Invitation for public engagement
Let them know about your health research priorities

DEADLINE 28 June 2019.
As a federally funded agency, the Canadian Institutes of Health Research (CIHR) believes strongly in the importance of engaging Canadians. The input we receive through these engagements is invaluable in guiding our discussions and informing our decision-making process. Please join the conversation!

Article recommended by Carole Estabrooks
Knowledge translation in health: how implementation science could contribute more

M. Wensing and R. Grol.
BMC Med 2019 May 7;17(1):88-019-1322-9
Despite increasing interest in research on how to translate knowledge into practice and improve healthcare, the accumulation of scientific knowledge in this field is slow. Few substantial new insights have become available in the last decade. MAIN BODY: Various problems hinder development in this field. There is a frequent misfit between problems and approaches to implementation, resulting in the use of implementation strategies that do not match with the targeted problems. The proliferation of concepts, theories and frameworks for knowledge transfer – many of which are untested – has not advanced the field. Stakeholder involvement is regarded as crucial for successful knowledge implementation, but many approaches are poorly specified and unvalidated. Despite the apparent decreased appreciation of rigorous designs for effect evaluation, such as randomized trials, these should remain within the portfolio of implementation research. Outcome measures for knowledge implementation tend to be crude, but it is important to integrate patient preferences and the increased precision of knowledge. CONCLUSIONS: We suggest that the research enterprise be redesigned in several ways to address these problems and enhance scientific progress in the interests of patients and populations. It is crucially important to establish substantial programmes of research on implementation and improvement in healthcare, and better recognize the societal and practical benefits of research.

CIHR Institute of Aging’s Strategic Plan
CIHR Institute of Aging Strategic Plan 2019-2021: Living Longer, Living Better

The CIHR Institute of Aging is at an important crossroad on its own trajectory; in fact, the Institute of Aging just reached the age of majority! Following the important contributions of Dr. Réjean Hébert and Professor Anne Martin-Matthews as the first two Scientific Directors the current Institute of Aging team has worked hard to place research on aging as a crucial component in the health and wellness agenda for Canadians. Supported by our Advisory Board, along with team members in Montreal and in Ottawa, in partnership with the other CIHR Institutes and with the support of and in partnership with our stakeholders, we are proud of what we have accomplished over our current mandate. But there is still much to do, many opportunities to explore, and many topics to address.

New article by Kate Seers
What enables older people to continue with their falls prevention exercises? A qualitative systematic review.
Non UofA Access

S. Finnegan, J. Bruce and K. Seers.
BMJ Open 2019 Apr 15;9(4):e026074-2018-026074
To review the qualitative literature that explores the barriers and facilitators to continued participation in falls prevention exercise after completion of a structured exercise programme. DESIGN: A systematic literature review with thematic synthesis of qualitative studies exploring older adults’ experiences of continued participation in falls prevention exercise. DATA SOURCES: Comprehensive searches were conducted in MEDLINE, PSYCHinfo, AMED, ASSIA, CINAHL and EMBASE from inception until November 2017. Additional studies were identified via searches of reference lists and citation tracking of relevant studies. ELIGIBILITY CRITERIA: Qualitative or mixed methods studies exploring experiences of community-dwelling older adults (65 years and over) participation in a falls prevention exercise programme including their experience of ongoing participation in exercise after the completion of a structured exercise programme. DATA EXTRACTION AND SYNTHESIS: Key characteristics including aim, participant characteristics, method of data collection, underpinning qualitative methodology and analytical approach were extracted and independently checked. Thematic synthesis was used to integrate findings. RESULTS: From 14 studies involving 425 participants, we identified three descriptive themes: identity, motivators/deterrents and nature of the intervention and one overarching analytical theme: agency. CONCLUSIONS: Older people have their own individual and meaningful rationale for either continuing or stopping exercise after completion of a structured falls prevention exercise programme. Exploring these barriers and facilitators to continued exercise is key during the intervention phase. It is important that health care professionals get to know the older person’s rationale and offer the best evidence-based practice and support to individuals, to ensure a smooth transition from their structured intervention towards longer-term exercise-related behaviour. PROSPERO REGISTRATION NUMBER: CRD42017082637.


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Grants & Awards

The Interstellar Initiative

The Interstellar Initiative brings together Early Career Investigators (ECIs) from around the world — selected via a competitive application process — and groups them into “Dream Teams.” With the guidance of leading senior researchers, each Dream Team develops a grant proposal centered on a novel scientific research question. The 2019-2020 Interstellar Initiative will address challenges in the area of Healthy Longevity. It will focus on exploring molecular, cellular, genetic, and physiological mechanisms of aging, and the relationship between aging and diseases such as cancers, neurodegenerative, cardiovascular, hormonal disorders, and other chronic age-related conditions with the ultimate goal of improving healthspan and preventing pathological aging.

Active & Assisted Living Programme

The AAL Call 2019 is open to developing ICT-based solutions targeting any application area(s) within the AAL domain. The solutions need to be embedded in the strategies of the participating end-user organisations, service providers and business partners.


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Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Culture and Change
Research Practice and Methodology


How was research engaged with and used in the development of 131 policy documents? Findings and measurement implications from a mixed methods study.
Non UofA Access

A. Williamson, S. R. Makkar and S. Redman.
Implement Sci 2019 Apr 30;14(1):44-019-0886-2
Much has been written about the use of evidence in policy; however, there is still little known about whether and how research is engaged with and used in policy development or the impact of reported barriers and facilitators. This paper aims to (1) describe the characteristics of 131 policy documents, (2) describe the ways in which research was engaged with (e.g. was searched for, appraised or generated) and used (e.g. to clarify understanding, persuade others or inform a policy) in the development of these policy documents, and (3) identify the most commonly reported barriers and facilitators and describe their association with research engagement and use. METHODS: Six health policy and program development agencies based in Sydney, Australia, contributed four recently finalised policy documents for consideration over six measurement periods. Structured, qualitative interviews were conducted with the policymakers most heavily involved in developing each of the 131 policy documents. Interviews covered whether and how research was engaged with and used in the development of the policy product and any barriers or facilitators related to this. Interviews were scored using the empirically validated SAGE tool and thematically analysed. Descriptive statistics were calculated for all key variables and comparisons made between agencies. Multiple regression analyses were used to estimate the impact of specific barriers and facilitators on research engagement and use. RESULTS: Our data shows large variations between policy agencies in the types of policy documents produced and the characteristics of these documents. Nevertheless, research engagement and use was generally moderate across agencies. A number of barriers and facilitators to research use were identified. No barriers were significantly associated with any aspects of research engagement or use. Access to consultants and relationships with researchers were both associated with increased research engagement but not use. Thus, access to consultants and relationships with researchers may increase the extent and quality of the evidence considered in policy development. CONCLUSIONS: Our findings suggest that those wishing to develop interventions and programs designed to improve the use of evidence in policy agencies might usefully target increasing access to consultants and relationships with researchers in order to increase the extent and quality of the research considered, but that a greater consideration of context might be required to develop strategies to increase evidence use.

Involving end-users in the design of an audit and feedback intervention in the emergency department setting – a mixed methods study.
Non UofA Access

W. K. van Deen, E. S. Cho, K. Pustolski, et al.
BMC Health Serv Res 2019 Apr 29;19(1):270-019-4084-3
Long length of stays (LOS) in emergency departments (ED) negatively affect quality of care. Ordering of inappropriate diagnostic tests contributes to long LOS and reduces quality of care. One strategy to change practice patterns is to use performance feedback dashboards for physicians. While this strategy has proven to be successful in multiple settings, the most effective ways to deliver such interventions remain unknown. Involving end-users in the process is likely important for a successful design and implementation of a performance dashboard within a specific workplace culture. This mixed methods study aimed to develop design requirements for an ED performance dashboard and to understand the role of culture and social networks in the adoption process. METHODS: We performed 13 semi-structured interviews with attending physicians in different roles within a single public ED in the U.S. to get an in-depth understanding of physicians’ needs and concerns. Principles of human-centered design were used to translate these interviews into design requirements and to iteratively develop a front-end performance feedback dashboard. Pre- and post- surveys were used to evaluate the effect of the dashboard on physicians’ motivation and to measure their perception of the usefulness of the dashboard. Data on the ED culture and underlying social network were collected. Outcomes were compared between physicians involved in the human-centered design process, those with exposure to the design process through the ED social network, and those with limited exposure. RESULTS: Key design requirements obtained from the interviews were ease of access, drilldown functionality, customization, and a visual data display including monthly time-trends and blinded peer-comparisons. Identified barriers included concerns about unintended consequences and the veracity of underlying data. The surveys revealed that the ED culture and social network are associated with reported usefulness of the dashboard. Additionally, physicians’ motivation was differentially affected by the dashboard based on their position in the social network. CONCLUSIONS: This study demonstrates the feasibility of designing a performance feedback dashboard using a human-centered design approach in the ED setting. Additionally, we show preliminary evidence that the culture and underlying social network are of key importance for successful adoption of a dashboard.


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Health Care Administration and Organization

Preparing Long-Term Care Staff to Meet the Needs of Aging Persons With Serious Mental Illness.
Non UofA Access

A. Muralidharan, W. L. Mills, D. R. Evans, D. Fujii and V. Molinari.
J Am Med Dir Assoc 2019 May 2
Individuals with serious mental illness (SMI; schizophrenia spectrum disorders and affective psychoses) are increasingly aging into older adulthood and are overrepresented in residential long-term care settings. The present study aimed to examine the preparedness of staff in these settings to care for individuals with SMI. DESIGN: A multidisciplinary US Department of Veterans Affairs (VA) workgroup of professionals with expertise in geriatric mental health collected voluntary feedback via online questionnaire as part of a quality improvement project. SETTING AND PARTICIPANTS: Respondents were mental health providers (N=51) embedded in VA nursing homes called Community Living Centers (CLCs). MEASURES: The questionnaire contained multiple-choice, Likert-type scale, and open-ended questions regarding the opportunities and challenges associated with caring for Veterans with SMI in CLCs. RESULTS: Respondents identified a lack of training of front-line staff as a key challenge in providing high-quality care to residents with SMI. Specifically, respondents indicated a need to increase staff knowledge about SMI symptoms and diagnoses, to improve staff communication and interactions with residents with SMI, and to decrease mental illness stigma among staff. CONCLUSIONS/IMPLICATIONS: The present study revealed significant areas of training need for front-line staff in nursing homes. Many perceived staff training needs overlap with the knowledge and skill set required to provide high-quality dementia care. Integrating training regarding the care of residents with SMI into dementia care training efforts may be a fruitful future direction. Strategies for this and a suggested curriculum are provided.

Unlicensed care homes in the United States: a clandestine sector of long-term care.
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M. Lepore, A. M. Greene, K. Porter, L. Lux, E. Vreeland and C. Hawes.
J Aging Soc Policy 2019 Jan-Feb;31(1):49-65
Residential care facilities operating without a state license are known to house vulnerable adults. Such unlicensed care homes (UCHs) commonly operate illegally, making them difficult to investigate. We conducted an exploratory, multimethod qualitative study of UCHs, including 17 subject matter expert interviews and site visits to three states, including a total of 30 stakeholder interviews, to understand UCH operations, services provided, and residents served. Findings indicate that various vulnerable groups reside in UCHs; some UCHs offer unsafe living environments; and some residents are reportedly abused, neglected, and financially exploited. Regulations, policies, and practices that might influence UCH prevalence are discussed.

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Health Care Innovation and Quality Assurance

Implementing a novel strategy for interprofessional medication review using collegial mentoring and systematic clinical evaluation in nursing homes (COSMOS).
Non UofA Access

C. Gulla, E. Flo, R. L. S. Kjome and B. S. Husebo.
BMC Geriatr 2019 May 7;19(1):130-019-1139-6
Multimorbid patients in nursing homes are prescribed long lists of medication, often without sufficient clinical evaluations beforehand. This results in poor clinical effects of the prescribed medication and significant side-effects, especially in patients with impaired cognition. The aim of this paper is to describe the process, content and implementation of a clinical medication review encompassing clinical testing and collegial support to prescribers. METHODS: The implementation process of a novel approach to medication review in nursing homes was logged thoroughly by structured staff feedback. Staff experienced promotors and barriers to implementation also were collected. The study was part of a cluster randomized controlled trial, in which 36 long-term care units received the COSMOS intervention. Nurses and physicians randomized to the intervention group participated in educational programs, training in clinical evaluation of the patients, and interprofessional medication review with collegial mentoring. RESULTS: The intervention group contained 297 patients from 36 nursing home units. There were 105 staff attendees for the education program. The units were served by 21 different physicians. Clinical medication reviews were performed in all units and all patients were assessed prior to the medication reviews. Of the 240 patients with a logged intervention process, 220 (92%) underwent a medication review. The intervention generated enthusiasm and improved communication among nursing staff and between nursing staff and physicians. The interprofessional discussions helped to facilitate difficult decisions pertaining to treatment levels. Reported barriers were lack of time, low engagement of all nursing staff and physicians, and ethical dilemmas. CONCLUSIONS: Clinical medication reviews were implemented for almost all patients, and every patient was systematically assessed prior to the medication review. The physicians perceived collegial mentoring as an asset, learning from each other facilitated decision making in terms of difficult aspects of prescribing. Knowledge about barriers and promotors can improve implementation of similar interventions in other nursing homes. TRIAL REGISTRATION: ( NCT02238652 ). Registered July 7th 2014.

The Implementation of Dementia Care Mapping in a Randomized Controlled Trial in Long-Term Care: Results of a Process Evaluation.
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C. A. Surr, A. W. Griffiths, R. Kelley, et al.
Am J Alzheimers Dis Other Demen 2019 May 5:1533317519845725
This study explored intervention implementation within a pragmatic, cluster randomized controlled trial of Dementia Care Mapping (DCM) in UK care homes. DCM is a practice development tool comprised of a 5 component cycle (staff briefing, mapping observations, data analysis and reporting, staff feedback, and action planning) that supports delivery of person-centered care. Two staff from the 31 intervention care homes were trained in DCM and asked to deliver 3 cycles over a 15-month period, supported by a DCM expert during cycle 1. Implementation data were collected after each mapping cycle. There was considerable variability in DCM implementation fidelity, dose, and reach. Not all homes trained 2 mappers on schedule, and some found it difficult to retain mappers. Only 26% of homes completed more than 1 cycle. Future DCM trials in care home settings should consider additional methods to support intervention completion including intervention delivery being conducted with ongoing external support.

Effects of Practice Turnover on Primary Care Quality Improvement Implementation.
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A. N. Baron, J. R. Hemler, S. M. Sweeney, et al.
Am J Med Qual 2019 Apr 29:1062860619844001
Primary care practices often engage in quality improvement (QI) in order to stay current and meet quality benchmarks, but the extent to which turnover affects practices’ QI ability is not well described. The authors examined qualitative data from practice staff and external facilitators participating in a large-scale QI initiative to understand the relationship between turnover and QI efforts. The examination found turnover can limit practices’ ability to engage in QI activities in various ways. When a staff member leaves, remaining staff often absorb additional responsibilities, and QI momentum slows as new staff are trained or existing staff are reengaged. Turnover alters staff dynamics and can create barriers to constructive working relationships and team building. When key practice members leave, they can take with them institutional memory about QI purpose, processes, and long-term vision. Understanding how turnover affects QI may help practices, and those helping them with QI, manage the disruptive effects of turnover.

Implementation of a national quality improvement program to enhance hand hygiene in nursing homes in Taiwan.
Non UofA Access

C. C. Lai, M. C. Lu, H. J. Tang, et al.
J Microbiol Immunol Infect 2019 Apr;52(2):345-351
This study investigated the cause of hand hygiene deficit, and further implemented a quality improvement program using WHO’s hand-hygiene strategy to enhance the compliance of hand hygiene in the nursing home in Taiwan. METHODS: This prospective study was conducted in eleven nursing homes in Taiwan from January 2015 to December 2016. After intervention, we monitor the compliance, and accuracy of hand hygiene. In addition, we also calculated the number of episodes of infection per 1000 resident-days in each nursing home in the intervention period (July-December 2015) and post-intervention period (January-October 2016). RESULTS: Overall, the consumption of alcohol-based handrubs increased from 10.1 ml per resident-day in intervention period to 12.2 ml per resident-day in post intervention period. The compliance of hand hygiene increased from 74% in intervention period to 79% in post-intervention period and the rate of correct hand hygiene increased from 81% in intervention period to 87% in post-intervention period. Most importantly, the infection density decreased from 2.39 per 1000 resident-day in intervention period to 1.89 per 1000 resident-day. CONCLUSIONS: A national quality-improvement program using WHO’s hand-hygiene strategy to enhance hand hygiene and reduce healthcare associated infection is effective in nursing homes in Taiwan.

Association of the Centers for Medicare & Medicaid Services’ National Partnership to Improve Dementia Care With the Use of Antipsychotics and Other Psychotropics in Long-term Care in the United States From 2009 to 2014.
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D. T. Maust, H. M. Kim, C. Chiang and H. C. Kales.
JAMA Intern Med 2018 May 1;178(5):640-647
The Centers for Medicare & Medicaid Services’ National Partnership to Improve Dementia Care in Nursing Homes (hereafter referred to as the partnership) was established to improve the quality of care for patients with dementia, measured by the rate of antipsychotic prescribing. Objective: To determine the association of the partnership with trends in prescribing of antipsychotic and other psychotropic medication among older adults in long-term care. Design, Setting, and Participants: This interrupted time-series analysis of a 20% Medicare sample from January 1, 2009, to December 31, 2014, was conducted among 637426 fee-for-service Medicare beneficiaries in long-term care with Part D coverage. Data analysis was conducted from May 1, 2017, to January 9, 2018. Main Outcomes and Measures: Quarterly prevalence of use of antipsychotic and nonantipsychotic psychotropic medications (antidepressants, mood stabilizers [eg, valproic acid and carbamazepine], benzodiazepines, and other anxiolytics or sedative-hypnotics). Results: Among the 637426 individuals in the study (446538 women and 190888 men; mean [SD] age at entering nursing home, 79.3 [12.1] years), psychotropic use was declining before initiation of the partnership with the exception of mood stabilizers. In the first quarter of 2009, a total of 31056 of 145841 patients (21.3%) were prescribed antipsychotics, which declined at a quarterly rate of -0.53% (95% CI, -0.63% to -0.44%; P < .001) until the start of the partnership. At that point, the quarterly rate of decline decreased to -0.29% (95% CI, -0.39% to -0.20%; P < .001), a postpartnership slowing of 0.24% per quarter (95% CI, 0.09%-0.39%; P = .003). The use of mood stabilizers was growing before initiation of the partnership and then accelerated after initiation of the partnership (rate, 0.22%; 95% CI, 0.18%-0.25%; P < .001; rate change, 0.14%; 95% CI, 0.10%-0.18%; P < .001), reaching 71492 of 355716 patients (20.1%) by the final quarter of 2014. Antidepressants were the most commonly prescribed medication overall: in the beginning of 2009, a total of 75841 of 145841 patients (52.0%) were prescribed antidepressants. As with antipsychotics, antidepressant use declined both before and after initiation of the partnership, but the decrease slowed (rate change, 0.34%; 95% CI, 0.18%-0.50%; P < .001). Findings were similar when limited to patients with dementia. Conclusions and Relevance: Prescribing of psychotropic medications to patients in long-term care has declined, although the partnership did not accelerate this decrease. However, the use of mood stabilizers, possibly as a substitute for antipsychotics, increased and accelerated after initiation of the partnership in both long-term care residents overall and in those with dementia. Measuring use of antipsychotics alone may be an inadequate proxy for quality of care and may have contributed to a shift in prescribing to alternative medications with a poorer risk-benefit balance.

Untapped potential: Investing in health and care data analytics (UK)

Health Foundation, 2019
Key points
The NHS generates a huge amount of data. Making better use of this growing mountain of information has the potential to improve care and how services are run.
Yet the NHS is failing to make the most of its data because there aren’t enough people with the right analytical skills to make sense of the information that is being collected.
More investment is needed in skilled analysts to unlock the full potential of NHS data to benefit patients.


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Organizational Culture and Change

Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions.
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T. J. Waltz, B. J. Powell, M. E. Fernandez, B. Abadie and L. J. Damschroder.
Implement Sci 2019 Apr 29;14(1):42-019-0892-4
A fundamental challenge of implementation is identifying contextual determinants (i.e., barriers and facilitators) and determining which implementation strategies will address them. Numerous conceptual frameworks (e.g., the Consolidated Framework for Implementation Research; CFIR) have been developed to guide the identification of contextual determinants, and compilations of implementation strategies (e.g., the Expert Recommendations for Implementing Change compilation; ERIC) have been developed which can support selection and reporting of implementation strategies. The aim of this study was to identify which ERIC implementation strategies would best address specific CFIR-based contextual barriers. METHODS: Implementation researchers and practitioners were recruited to participate in an online series of tasks involving matching specific ERIC implementation strategies to specific implementation barriers. Participants were presented with brief descriptions of barriers based on CFIR construct definitions. They were asked to rank up to seven implementation strategies that would best address each barrier. Barriers were presented in a random order, and participants had the option to respond to the barrier or skip to another barrier. Participants were also asked about considerations that most influenced their choices. RESULTS: Four hundred thirty-five invitations were emailed and 169 (39%) individuals participated. Respondents had considerable heterogeneity in opinions regarding which ERIC strategies best addressed each CFIR barrier. Across the 39 CFIR barriers, an average of 47 different ERIC strategies (SD = 4.8, range 35 to 55) was endorsed at least once for each, as being one of seven strategies that would best address the barrier. A tool was developed that allows users to specify high-priority CFIR-based barriers and receive a prioritized list of strategies based on endorsements provided by participants. CONCLUSIONS: The wide heterogeneity of endorsements obtained in this study’s task suggests that there are relatively few consistent relationships between CFIR-based barriers and ERIC implementation strategies. Despite this heterogeneity, a tool aggregating endorsements across multiple barriers can support taking a structured approach to consider a broad range of strategies given those barriers. This study’s results point to the need for a more detailed evaluation of the underlying determinants of barriers and how these determinants are addressed by strategies as part of the implementation planning process.

The improvement journey: why organisation-wide improvement in health care matters, and how to get started (UK)

Health Foundation, 2019
The Health Foundation’s report investigates lessons derived from sponsoring and evaluating quality improvement, whether at team, organisation and / or system levels. Case studies covering three NHS trusts in England with a CQC rating of “Outstanding” and which implemented organisational approaches to quality improvement, are provided on:​ East London NHS Foundation Trust; Northumbria Healthcare NHS Foundation Trust; Western Sussex Hospitals NHS Foundation Trust.

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Research Practice and Methodology

Developing Mixed Methods Crossover Analysis Approaches
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John H. Hitchcock and Anthony J. Onwuegbuzie.
Journal of Mixed Methods Research 2019 04/17; 2019/05:1558689819841782
Onwuegbuzie and Hitchcock (2015) provided an initial framework for conceptualizing and conducting advanced-level mixed analysis approaches. In the present article, we build on these efforts by altering the framework to focus on crossover analyses, which might help analysts see the various component steps that can go into crossover analyses and innovate their own forms of crossover work. In applying the framework, we specify three advanced-level crossover mixed analysis approaches: ethnographic crossover analyses, missing data crossover analyses, and nonverbal communication crossover analyses. The ideas presented here might inspire others to apply these crossover analysis approaches in their own work and/or to use the framework to innovate yet more crossover approaches.

The Pursuit of Success in Academia: Plato’s Ghost Asks “What then?”
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A. R. Elangovan and Andrew J. Hoffman.
Journal of Management Inquiry 2019 03/15; 2019/05:1056492619836729
What do we pursue as we seek success in academia? For most, the path to academic success focuses narrowly on A-level journal publications, which has caused a stealthy but steady erosion in the very essence of academia. In this essay, we explore that erosion by drawing on the poem by William Butler Yeats titled ?What then?? to highlight the questions, doubts, and perils that lie at each of the four stages of academic life: doctoral student, junior professor, senior professor, and professor emeritus. We then offer a new set of questions that academics may ask at each stage to remain true to their sense of scholarly identity and calling. Our hope is to shine a critical spotlight on the modal journey and inspire a confident and courageous few to deviate from that well-trodden path and chart a course that is truer to the essence, purpose, and potential of academia.

A method to reduce imbalance for site-level randomized stepped wedge implementation trial designs.
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R. A. Lew, C. J. Miller, B. Kim, H. Wu, K. Stolzmann and M. S. Bauer.
Implement Sci 2019 May 3;14(1):46-019-0893-3
Controlled implementation trials often randomize the intervention at the site level, enrolling relatively few sites (e.g., 6-20) compared to trials that randomize by subject. Trials with few sites carry a substantial risk of an imbalance between intervened (cases) and non-intervened (control) sites in important site characteristics, thereby threatening the internal validity of the primary comparison. A stepped wedge design (SWD) staggers the intervention at sites over a sequence of times or time waves until all sites eventually receive the intervention. We propose a new randomization method, sequential balance, to control time trend in site allocation by minimizing sequential imbalance across multiple characteristics. We illustrate the new method by applying it to a SWD implementation trial. METHODS: The trial investigated the impact of blended internal-external facilitation on the establishment of evidence-based teams in general mental health clinics in nine US Department of Veterans Affairs medical centers. Prior to randomization to start time, an expert panel of implementation researchers and health system program leaders identified by consensus a series of eight facility-level characteristics judged relevant to the success of implementation. We characterized each of the nine sites according to these consensus features. Using a weighted sum of these characteristics, we calculated imbalance scores for each of 1680 possible site assignments to identify the most sequentially balanced assignment schemes. RESULTS: From 1680 possible site assignments, we identified 34 assignments with minimal imbalance scores, and then randomly selected one assignment by which to randomize start time. Initially, the mean imbalance score was 3.10, but restricted to the 34 assignments, it declined to 0.99. CONCLUSIONS: Sequential balancing of site characteristics across groups of sites in the time waves of a SWD strengthens the internal validity of study conclusions by minimizing potential confounding. TRIAL REGISTRATION: Registered at as clinical trials # NCT02543840 ; entered 9/4/2015.

A novel counterbalanced implementation study design: methodological description and application to implementation research.
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M. N. Sarkies, E. H. Skinner, K. A. Bowles, et al.
Implement Sci 2019 May 2;14(1):45-019-0896-0
Implementation research is increasingly being recognised for optimising the outcomes of clinical practice. Frequently, the benefits of new evidence are not implemented due to the difficulties applying traditional research methodologies to implementation settings. Randomised controlled trials are not always practical for the implementation phase of knowledge transfer, as differences between individual and organisational readiness for change combined with small sample sizes can lead to imbalances in factors that impede or facilitate change between intervention and control groups. Within-cluster repeated measure designs could control for variance between intervention and control groups by allowing the same clusters to receive a sequence of conditions. Although in implementation settings, they can contaminate the intervention and control groups after the initial exposure to interventions. We propose the novel application of counterbalanced design to implementation research where repeated measures are employed through crossover, but contamination is averted by counterbalancing different health contexts in which to test the implementation strategy. METHODS: In a counterbalanced implementation study, the implementation strategy (independent variable) has two or more levels evaluated across an equivalent number of health contexts (e.g. community-acquired pneumonia and nutrition for critically ill patients) using the same outcome (dependent variable). This design limits each cluster to one distinct strategy related to one specific context, and therefore does not overburden any cluster to more than one focussed implementation strategy for a particular outcome, and provides a ready-made control comparison, holding fixed. The different levels of the independent variable can be delivered concurrently because each level uses a different health context within each cluster to avoid the effect of treatment contamination from exposure to the intervention or control condition. RESULTS: An example application of the counterbalanced implementation design is presented in a hypothetical study to demonstrate the comparison of ‘video-based’ and ‘written-based’ evidence summary research implementation strategies for changing clinical practice in community-acquired pneumonia and nutrition in critically ill patient health contexts. CONCLUSION: A counterbalanced implementation study design provides a promising model for concurrently investigating the success of research implementation strategies across multiple health context areas such as community-acquired pneumonia and nutrition for critically ill patients.

Productivity, prominence, and the effects of academic environment.
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S. F. Way, A. C. Morgan, D. B. Larremore and A. Clauset.
Proc Natl Acad Sci U S A 2019 Apr 29
Faculty at prestigious institutions produce more scientific papers, receive more citations and scholarly awards, and are typically trained at more-prestigious institutions than faculty with less prestigious appointments. This imbalance is often attributed to a meritocratic system that sorts individuals into more-prestigious positions according to their reputation, past achievements, and potential for future scholarly impact. Here, we investigate the determinants of scholarly productivity and measure their dependence on past training and current work environments. To distinguish the effects of these environments, we apply a matched-pairs experimental design to career and productivity trajectories of 2,453 early-career faculty at all 205 PhD-granting computer science departments in the United States and Canada, who together account for over 200,000 publications and 7.4 million citations. Our results show that the prestige of faculty’s current work environment, not their training environment, drives their future scientific productivity, while current and past locations drive prominence. Furthermore, the characteristics of a work environment are more predictive of faculty productivity and impact than mechanisms representing preferential selection or retention of more-productive scholars by more-prestigious departments. These results identify an environmental mechanism for cumulative advantage, in which an individual’s past successes are “locked in” via placement into a more prestigious environment, which directly facilitates future success. The scientific productivity of early-career faculty is thus driven by where they work, rather than where they trained for their doctorate, indicating a limited role for doctoral prestige in predicting scientific contributions.

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Bring the Outside In: Providing Accessible Experiences Through VR for People with Dementia in Locked Psychiatric Hospitals
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Luma Tabbaa, Chee Siang Ang, Vienna Rose, et al.
Proceedings of the 2019 CHI Conference on Human Factors in Computing Systems New York, NY, USA: ACM; 2019.
Many people with dementia (PWD) residing in long-term care may face barriers in accessing experiences beyond their physical premises; this may be due to location, mobility constraints, legal mental health act restrictions, or offence-related restrictions. In recent years, there have been research interests towards designing non-pharmacological interventions aiming to improve the Quality of Life (QoL) for PWD within long-term care. We explored the use of Virtual Reality (VR) as a tool to provide 360°-video based experiences for individuals with moderate to severe dementia residing in a locked psychiatric hospital. We discuss at depth the appeal of using VR for PWD, and the observed impact of such interaction. We also present the design opportunities, pitfalls, and recommendations for future deployment in healthcare services. This paper demonstrates the potential of VR as a virtual alternative to experiences that may be difficult to reach for PWD residing within locked setting.

Nursing Home Residents by Human Immunodeficiency Virus Status: Characteristics, Dementia Diagnoses, and Antipsychotic Use.
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S. C. Miller, S. Cai, L. A. Daiello, T. I. Shireman and I. B. Wilson.
J Am Geriatr Soc 2019 May 7
Given an aging human immunodeficiency virus (HIV) population, we aimed to determine the prevalence of HIV for long-stay residents in US nursing homes (NHs) between 2001 and 2010 and to compare characteristics and diagnoses of HIV-positive (HIV+) and negative (HIV-) residents. Also, for residents with dementia diagnoses, we compared antipsychotic (APS) medication receipt by HIV status. DESIGN: A cross-sectional comparative study. SETTING: NHs in the 14 states accounting for 75% of persons living with HIV. PARTICIPANTS: A total of 9 245 009 long-stay NH residents. MEASUREMENTS: Using Medicaid fee-for-service claims data in the years 2001 to 2010, together with Medicare resident assessment and Chronic Condition Warehouse data, we identified long-stay (more than 89 days) NH residents by HIV status and dementia presence. We examined dementia presence by age groups and APS medication receipt by younger (aged younger than 65 years) vs older (aged 65 years or older) residents, using logistic regression. RESULTS: Between 2001 and 2010, the prevalence of long-stay residents with HIV in NHs increased from 0.7% to 1.2%, a 71% increase. Long-stay residents with HIV were younger and less often female or white. For younger NH residents, rates of dementia were 20% and 16% for HIV+ and HIV- residents, respectively; they were 53% and 57%, respectively, for older residents. In adjusted analyses, younger HIV+ residents with dementia had greater odds of APS medication receipt than did HIV- residents (AOR = 1.3; 95% confidence interval [CI] = 1.2-1.4), but older HIV residents had lower odds (AOR = 0.9; 95% CI = 0.8-0.9). CONCLUSION: The prevalence of long-stay HIV+ NH residents has increased over time, and given the rapid aging of the HIV population, this increase is likely to have continued. This study raises concern about potential differential quality of care for (younger) residents with HIV in NHs, but not for those aged 65 years and older. These findings contribute to the evidence base needed to ensure high-quality care for younger and older HIV+ residents in NHs.

Recommendations for the prevention of deaths among nursing home residents with unexplained absences.
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M. H. Woolford, L. Bugeja, C. Weller, J. Boag, M. Willoughby and J. E. Ibrahim.
Int J Older People Nurs 2019 May 7:e12237
Unexplained absences (UAs) contribute to the mortality and morbidity rates in the nursing home (NH) population. Valuing expert professional knowledge and skills is central to the achievement of improved care in NHs. This study developed and prioritised recommendations to prevent deaths of NH residents (NHRs) with UAs. METHODS: Two expert consultation forums using the modified nominal group technique to develop recommendations were conducted, followed by an online survey to prioritise the most important recommendations for implementation. A framework applying the temporal dimension (“pre-event,” “event” and “post-event”) of an internationally accepted injury prevention framework, Haddon’s Matrix, was applied to the recommendations. Participants were purposively sampled and identified via aged care organisations; and were selected based on their experience in aged care practice, policy, research, elder rights, seniors’ law, or missing persons search and rescue (SAR). RESULTS: Forum one comprised six, and forum two comprised nine experts from mixed disciplines. Seven participants completed the online survey. Twenty recommendations to prevent future injury and death were developed, five of which were prioritised for implementation in the aged care sector. In order of priority, these include: universal UA definition; mandated SAR plan, early assessment of NHRs; unmet needs behavioural assessments; and participation in decision-making. CONCLUSIONS: The recommendations cover the broad spectrum of complex issues raised in managing unexplained absences, and are a vital first step towards informing care providers, governments and SAR teams about how to prevent injury and death of NHRs in residents with UAs. Future research should explore how to translate and evaluate the recommendations into practice.

Effect of Therapeutic Touch on Sleep Quality in Elders Living at Nursing Homes
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H. Bagci and S. Cinar Yucel.
J Relig Health 2019 May 6
This study was carried out to investigate the effect of therapeutic touch on sleep quality in the elderly people living in the nursing homes. The study is a randomized controlled experimental study (pretest-posttest control group). The sample of the research consisted of 25 elderly people. As a result of the study, although there was a significant increase (p 0.05). Therapeutic touch is an effective method of improving the sleep quality of the elders living at a nursing home.

Ethical Challenges in Caring for Unrepresented Adults: A Qualitative Study of Key Stakeholders
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A. Verma, A. K. Smith, K. L. Harrison and A. H. Chodos.
J Am Geriatr Soc 2019 May 6
The decision-making process on behalf of unrepresented adults (ie, those who lack capacity to make medical decisions and have no identifiable surrogate) is at risk for not incorporating their interests, raising ethical concerns. We performed semistructured interviews with key stakeholders across multiple sectors in an urban county who participate in the care of or decision-making process for unrepresented adults. This included a safety net healthcare system, social services, and legal services. Participants were healthcare, social service, and legal professionals who worked with unrepresented adults (n = 25). Our interview questions explored the current process for proxy decision making in cases of unrepresented adults and potential alternatives. We recorded, transcribed, and analyzed interviews using the constant comparative method to identify major themes related to ethical challenges if they were raised. Participants grappled with multiple ethical challenges around the care of unrepresented adults. Themes described by participants were: (1) prioritizing autonomy; (2) varying safety thresholds; (3) distributing resources fairly; and (4) taking a moral toll on stakeholders. In conclusion, all stakeholders identified ethical challenges in caring for unrepresented adults. An applied ethical framework that takes these dilemmas into account could improve ethical practice for unrepresented adults and lessen the emotional toll on stakeholders.

Nonpharmacological Interventions for Anxiety and Dementia in Nursing Homes: A Systematic Review.
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C. Brown Wilson, L. Arendt, M. Nguyen, T. L. Scott, C. C. Neville and N. A. Pachana.
Gerontologist 2019 May 3
Anxiety is a major mental disorder in later life that impacts on activities of daily living and quality of life for adults living with dementia in nursing homes. The aim of this article was to systematically review nonpharmacological interventions for older adults living in nursing homes who experience comorbid anxiety and dementia. METHOD: A systematic literature search was conducted across key databases (Cinahl, ASSIA, Cochrane reviews and trials, psycARTICLES, psycINFO, and PubMed) to identify studies measuring anxiety as an outcome for an intervention for older adults living with dementia in nursing homes, up to December 31, 2017. RESULTS: The search yielded a total of 1,925 articles with 45 articles accessed for full article review. A total of 13 articles were included in this review following quality appraisal based on Cochrane methodology with six different anxiety measures used. The studies included were moderate to high-quality randomized control trials although heterogeneity precluded a combined meta-analysis. CLINICAL IMPLICATIONS: The most common interventions used to address anxiety in this population were music therapy and activity-based interventions although there was limited evidence for the efficacy of either intervention. Little is known about effective nonpharmacological treatment for anxiety for people living with dementia in nursing homes. Further research using consistent measurement tools and time points is required to identify effective interventions to improve the quality of life for people living with both dementia and anxiety in nursing homes.

Preventable Hospitalizations Among Nursing Home Residents With Dementia and Behavioral Health Disorders.
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H. Temkin-Greener, X. Cen, M. J. Hasselberg and Y. Li.
J Am Med Dir Assoc 2019 Apr 28
Nursing home (NH) residents with Alzheimer’s disease/related dementias (ADRD) and/or behavioral health disorders (BHD) are at high risk of hospitalizations, many of which are potentially avoidable. Empirical evidence regarding potentially avoidable hospitalizations (PAHs) among these residents is quite sparse and mixed. The objectives of this study were to (1) examine the risk of PAH among residents with ADRD only, BHD only, ADRD and BHD compared to residents with neither and (2) identify associations between individual- and facility-level factors and PAH in these subgroups. DESIGN: Retrospective, CY2014-2015. SETTING AND PARTICIPANTS: Long-term residents age 65+ (N = 807,630) residing in 15,234 NHs. METHODS: We employed the Minimum Data Set, MedPAR, Medicare beneficiary summary, and Nursing Home Compare. Hospitalization risk was the outcome of interest. Individual-level covariates were used to adjust for health conditions. Facility-level covariates and state dummies were included. Multinomial logistic regression models were fit to estimate the risk of PAH and non-potentially avoidable hospitalizations (N-PAH). RESULTS: Compared to residents without ADRD or BHD, those with ADRD had at least a 10% lower relative risk ratio (RRR) of N-PAH and a significantly lower risk of PAH, at 16% (P < .0001). Residents with BHD only had a statistically higher, but clinically very modest (RRR = 1.03) risk of N-PAH, with no difference in the risk of PAH. Focusing on specific BHD conditions, we found no difference in N-PAH or PAH among residents with depression, lower PAH risk among those with schizophrenia/psychosis (RRR = 0.92), and an increased risk of both N-PAH (RRR = 1.15) and PAH (RRR = 1.09) among residents with bipolar disorders. CONCLUSIONS AND RELEVANCE: We observed a lower risk of PAH and N-PAH among residents with ADRD, with the risk for residents with BHD varying by condition. Substantial variations in PAH and N-PAH were evident across states. Future research is needed to identify state-level modifiable factors that explain these variations.

Associations between Nutritional Status and Health-Related Quality of Life among Long-Term Care Residents in Helsinki.
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K. S. Salminen, M. H. Suominen, H. Soini, et al.
J Nutr Health Aging 2019;23(5):474-478
We evaluated the associations between nutritional status and health-related quality-of-life (HRQoL) among older long-term care residents in Helsinki. DESIGN AND PARTICIPANTS: All 3767 older (>/=65 years) long-term care residents in Helsinki in 2017 were invited to participate in this cross-sectional study. After refusals and exclusions of residents without sufficient information, 2160 residents remained. MEASUREMENTS: Data on characteristics, nutritional status (Mini Nutritional Assessment, MNA) and HRQoL (15D) were collected by trained nurses. RESULTS: Of the participants, 64% were at-risk of malnutrition and 18% suffered from malnutrition. Residents in the “malnourished” group were more dependent in activities of daily living (ADL) functioning, suffered more often from dementia, had lower cognitive level, used less medications, and were eating more often inadequately. HRQoL was statistically significantly associated with MNA total score in both female and male residents. There was a curvilinear correlation between MNA and 15D score in females: 0.50 (95% CI 0.46 to 0.53) and males: 0.56 (95% CI 0.50 to 0.61). In partial correlation analysis, all dimensions of 15D, except for sleeping and breathing, were positively associated with MNA score. In these analyses no significant differences emerged between males and females when the results were adjusted for age and dementia. CONCLUSIONS: Nutrition plays an important role in HRQoL among older long-term care residents.

Understanding the factors associated with patients with dementia achieving their preferred place of death: a retrospective cohort study.
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N. Wiggins, J. Droney, K. Mohammed, J. Riley and K. E. Sleeman.
Age Ageing 2019 May 1;48(3):433-43
Dying in one’s preferred place is a quality marker for end-of-life care. Little is known about preferred place of death, or the factors associated with achieving this, for people with dementia. AIMS: to understand preferences for place of death among people with dementia; to identify factors associated with achieving these preferences. POPULATION: adults with a diagnosis of dementia who died between December 2015 and March 2017 and who were registered on Coordinate My Care, an Electronic Palliative Care Coordination System. DESIGN: retrospective cohort study. ANALYSIS: multivariable logistic regression investigated factors associated with achieving preferred place of death. RESULTS: we identified 1,047 people who died with dementia; information on preferred and actual place of death was available for 803. Preferred place of death was most commonly care home (58.8%, n = 472) or home (39.0%, n = 313). Overall 83.7% (n = 672) died in their preferred place. Dying in the preferred place was more likely for those most functionally impaired (OR 1.82 95% CI 1.06-3.13), and with a ceiling of treatment of ‘symptomatic relief only’ (OR 2.65, 95% CI 1.37-5.14). It was less likely for people with a primary diagnosis of cancer (OR 0.52, 95% CI 0.28-0.97), those who were ‘for’ cardio-pulmonary resuscitation (OR 0.32, 95% CI 0.16-0.62) and those whose record was created longer before death (51-250 days (ref <50 days) OR 0.60, 95% CI 0.38-0.94). CONCLUSIONS: most people with dementia want to die in a care home or at home. Achieving this is more likely where goals of treatment are symptomatic relief only, indicating the importance of advance care planning.

“She Had a Smile on Her Face as Wide as the Great Australian Bite”: A Qualitative Examination of Family Perceptions of a Therapeutic Robot and a Plush Toy.
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W. Moyle, M. Bramble, C. J. Jones and J. E. Murfield.
Gerontologist 2019 Jan 9;59(1):177-185
Recent years have seen social robotic pets introduced as a means of treating behavioral and psychological symptoms of dementia, and many show promising potential. In this study, we sought to explore family members’ perceptions of the Japanese-developed baby harp seal, Paro (version 9), and a look-alike, nonrobotic Plush Toy, when used by their relative with dementia for 15 min, 3 afternoons per week for 10 weeks. Research Design and Method: The study employed a descriptive qualitative approach, which was nested within a larger cluster randomized controlled trial. A convenience sample of 20 family members (n = 10 each from the Paro and Plush Toy conditions) with relatives in 9 long-term care facilities in Queensland, Australia, completed individual semi-structured interviews (telephone or face-to-face). Inductive, data-driven thematic analysis of the data was undertaken with the assistance of the qualitative management software, ATLAS.ti(R). Results: Family members of long-term care residents with dementia expressed positive perceptions of the Paro, perceiving that it improved mood, reduced agitation, and provided opportunity for communication for their relative. Negative perceptions of the Plush Toy were given by family members, primarily because of its lack of movement and engagement. Conclusion: Family members were keen for their older relative with dementia to use a social robot that moved and engaged with them, and Plush Toys that were static and unresponsive were perceived as being unimportant in improving quality of life. However, the current cost of Paro was identified by family members as a major limitation to use.

Long-term success of oral health intervention among care-dependent institutionalized seniors: Findings from a controlled clinical trial.
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F. S. Schwindling, J. Krisam, A. J. Hassel, P. Rammelsberg and A. Zenthofer.
Community Dent Oral Epidemiol 2018 Apr;46(2):109-117
The purpose of this work was to investigate the long-term effectiveness of oral health education of caregivers in nursing homes with care-dependent and cognitively impaired residents. METHODS: Fourteen nursing homes with a total of 269 residents were allocated to a control group, with continued normal care, or to an intervention group. Allocation was performed at nursing home level. In the intervention group, caregivers were given oral health education, and ultrasonic cleaning devices were provided to clean removable prostheses. Oral health was assessed at baseline and after 6 and 12 months by use of the Plaque Control Record (PCR), Gingival Bleeding Index (GBI), Community Periodontal Index of Treatment Needs (CPITN) and Denture Hygiene Index (DHI). Mixed models for repeated measures were performed for each target variable, with possible confounding factors (intervention/control group, age, sex, residence location and care-dependence). RESULTS: In the control group, no changes of target variables were observed between baseline and the 6- and 12-month follow-ups. After 6 and 12 months, PCR and DHI were significantly improved in the intervention group. For PCR, the intergroup difference of improvements was -14.4 (95% CI: -21.8; -6.9) after 6 months. After 12 months, the difference was -16.2 (95% CI: -27.7; -4.7). For DHI, the intergroup difference compared to baseline was -15 (95% CI: -23.6; -6.5) after 6 months and -13.3 (95% CI: -24.9; -1.8) after 12 months. There was neither a statistically significant effect on GBI nor on CPITN. Care-dependency showed a substantial trend to smaller improvements in PCR (P = .074), while an inverse effect was apparent for DHI (P < .001). CONCLUSIONS: Education of caregivers improves and maintains the oral health of care-dependent nursing home residents over longer periods. Use of ultrasonic devices is a promising means of improving denture hygiene among the severely care-dependent. Such interventions can be easily and cheaply implemented in routine daily care.


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