August 27, 2019



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Portal for Elder Research, Care and Innovation (PERCI) poised to transform aging in Canada
Estabrooks’ $329K John R. Evans Leaders Fund Grant mitigates Canada’s looming long-term care population explosion through accessible data sharing

Canada’s long-term care (LTC) system, already overextended, faces unprecedented growth in the coming decades. With estimates of 63% more long-term care residents by 2036 — and ballooning costs to taxpayers and families — this unprecedented increase threatens to burden Canada’s already stretched health systems and staff to breaking point.

But where the rest of the country sees a problem, Dr. Carole Estabrooks and her team see a research challenge they’re uniquely positioned to help solve.

New article by Jo Rycroft-Malone
Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence
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C. Burton, L. Williams, T. Bucknall, et al.
Syst Rev 2019 Aug 5;8(1):194-019-1111-8
Strategies to improve the effectiveness and quality of health and care have predominantly emphasised the implementation of new research and evidence into service organisation and delivery. A parallel, but less understood issue is how clinicians and service leaders stop existing practices and interventions that are no longer evidence based, where new evidence supersedes old evidence, or interventions are replaced with those that are more cost effective. The aim of this evidence synthesis is to produce meaningful programme theory and practical guidance for policy makers, managers and clinicians to understand how and why de-implementation processes and procedures can work. METHODS AND ANALYSIS: The synthesis will examine the attributes or characteristics that constitute the concept of de-implementation. The research team will then draw on the principles of realist inquiry to provide an explanatory account of how, in what context and for whom to explain the successful processes and impacts of de-implementation. The review will be conducted in four phases over 18 months. Phase 1: develop a framework to map the preliminary programme theories through an initial scoping of the literature and consultation with key stakeholders. Phase 2: systematic searches of the evidence to develop the theories identified in phase 1. Phase 3: validation and refinement of programme theories through stakeholder interviews. Phase 4: formulating actionable recommendations for managers, commissioners and service leaders about what works through different approaches to de-implementation. DISCUSSION: This evidence synthesis will address gaps in knowledge about de-implementation across health and care services and ensure that guidance about strategies and approaches accounts for contextual factors, which may be operating at different organisational and decision-making levels. Through the development of the programme theory, which explains what works, how and under which circumstances, findings from the evidence synthesis will support managers and service leaders to make measured decisions about de-implementation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017081030.

New article by Susan Slaughter
Resident and Staff Mealtime Actions and Energy Intake of Long-Term Care Residents With Cognitive Impairment: Analysis of the Making the Most of Mealtimes Study
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K. Mann, C. O. Lengyel, S. E. Slaughter, N. Carrier and H. Keller.
J Gerontol Nurs 2019 Aug 1;45(8):32-42
Long-term care (LTC) residents with cognitive impairment (CI) are at increased risk of malnutrition, often explained by mealtime actions (e.g., resident eating challenges, staff actions with eating assistance). The purpose of the current study was to examine the association between mealtime actions and energy intake of LTC residents with CI. Participants with CI (N = 353) from 32 LTC in four provinces were included. Mealtime actions were assessed using the Relational Behavioural Scale, Edinburgh Feeding Evaluation in Dementia (Ed-FED), nine additional eating challenges, and the Mealtime Relational Care Checklist. Several eating challenges (e.g., refusal to eat, turning head away) were associated with poor energy intake. Adjusting for age and sex, partial eating assistance and total Ed-FED score were associated with poor intake, whereas dysphagia risk and often receiving assistance were associated with better intake. Interventions to support eating independence and address residents’ eating challenges in LTC are needed to improve their intakes.

 

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Health Care Administration and Organization
Health Care Innovation and Quality Assurance
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Aging

KT

Creating a dementia enabling university using a Knowledge Translation approach: Innovative practice
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L. Phillipson, R. Fleming, K. Swaffer, et al.
Dementia (London) 2019 Aug 13:1471301219868624.
Universities can promote social impact by developing a dementia literate workforce. The Dementia Enabling University Strategy utilised a knowledge translation framework in an Australian university to inspire and support academics to engage students and consider how their skills and knowledge could contribute to the creation of more supportive environments for people with dementia. Dementia Enabling University Strategy ran across eight disciplines: law, media, social sciences, public health, engineering, business, marketing and psychology and was successful in engaging university academics and students. However, a longer term strategy is needed to embed ‘dementia’ as core business to the university impact agenda.

Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.
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J. C. Moullin, K. S. Dickson, N. A. Stadnick, B. Rabin and G. A. Aarons.
Implement Sci 2019 Jan 5;14(1):1-018-0842-6
Effective implementation of evidence-based practices (EBPs) remains a significant challenge. Numerous existing models and frameworks identify key factors and processes to facilitate implementation. However, there is a need to better understand how individual models and frameworks are applied in research projects, how they can support the implementation process, and how they might advance implementation science. This systematic review examines and describes the research application of a widely used implementation framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. METHODS: A systematic literature review was performed to identify and evaluate the use of the EPIS framework in implementation efforts. Citation searches in PubMed, Scopus, PsycINFO, ERIC, Web of Science, Social Sciences Index, and Google Scholar databases were undertaken. Data extraction included the objective, language, country, setting, sector, EBP, study design, methodology, level(s) of data collection, unit(s) of analysis, use of EPIS (i.e., purpose), implementation factors and processes, EPIS stages, implementation strategy, implementation outcomes, and overall depth of EPIS use (rated on a 1-5 scale). RESULTS: In total, 762 full-text articles were screened by four reviewers, resulting in inclusion of 67 articles, representing 49 unique research projects. All included projects were conducted in public sector settings. The majority of projects (73%) investigated the implementation of a specific EBP. The majority of projects (90%) examined inner context factors, 57% examined outer context factors, 37% examined innovation factors, and 31% bridging factors (i.e., factors that cross or link the outer system and inner organizational context). On average, projects measured EPIS factors across two of the EPIS phases (M = 2.02), with the most frequent phase being Implementation (73%). On average, the overall depth of EPIS inclusion was moderate (2.8 out of 5). CONCLUSION: This systematic review enumerated multiple settings and ways the EPIS framework has been applied in implementation research projects, and summarized promising characteristics and strengths of the framework, illustrated with examples. Recommendations for future use include more precise operationalization of factors, increased depth and breadth of application, development of aligned measures, and broadening of user networks. Additional resources supporting the operationalization of EPIS are available.

 

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Health Care Administration and Organization

Perspectives of Healthcare Professionals on Meaningful Activities for Persons with Dementia in Transition from Home to a Nursing Home: An Explorative Study.
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M. Groenendaal, A. Loor, M. Trouw, W. P. Achterberg and M. A. A. Caljouw.
Healthcare (Basel) 2019 Aug 19;7(3):10.3390/healthcare7030098
Meaningful activities can enhance quality of life, a sense of connectedness, and personhood for persons with dementia. Healthcare professionals play an important role in maintaining meaningful activities, but little is currently known about the impact of the transition from home to nursing home on these activities. This study explored the experiences of professionals in four Dutch nursing homes, identifying facilitators and barriers to the maintenance of meaningful activities during the transition. A qualitative explorative design was used. Data were collected using focus groups and analyzed using thematic analysis. Twenty-two professionals participated in four focus groups, and three themes were identified: (1) a lack of awareness and attention for meaningful activities; (2) activities should be personalized and factors such as person characteristics, interests, the social and physical environment, and specific information such as roles, routines, activities, and personal issues play an important role in maintaining activities; (3) in the organization of care, a person-centered care vision, attitudes of professionals and interdisciplinary collaboration facilitate maintenance of meaningful activities. Healthcare professionals felt that meaningful activities are difficult to maintain and that improvements are needed. Our study provides suggestions on how to maintain meaningful activities for persons with dementia prior, during and after the transition.

Economic Impact of Pharmacist-Participated Medication Management for Elderly Patients in Nursing Homes: A Systematic Review.
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A. Kwak, Y. J. Moon, Y. K. Song, H. Y. Yun and K. Kim.
Int J Environ Res Public Health 2019 Aug 16;16(16):10.3390/ijerph16162955
This systematic review examined the varied studies that have assessed the economic impact of pharmacist-participated medication management for nursing home residents older than 65 years of age. The articles published during 1990-2017 were found through PubMed, EMBASE and Ovid Medline. After the selection process by independent reviewers, a total of 12 studies were included. The quality of the selected articles was assessed using the Effective Public Health Practice Project checklist for economic studies. The articles were highly heterogeneous in terms of study design, pharmacist participation type, and measures of economic outcome. Therefore, the results are presented narratively according to the type of pharmacist involvement featured in the articles: interprofessional networks, interprofessional coordination, or interprofessional teamwork. Of the eight studies performing statistical comparison analyses, one study of interprofessional coordination and three of interprofessional teamwork showed statistically significant positive economic outcomes. The remaining four studies showed non-significant tendencies towards favorable economic outcomes. This review provides insights into the essential features of successful pharmacist-participated medication management for elderly patients in nursing homes.

The use of direct care in nursing home residents: A longitudinal cohort study over 3 years.
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C. Vossius, G. Selbaek, J. Saltyte Benth, A. Wimo and S. Bergh.
Int J Geriatr Psychiatry 2019 Feb;34(2):337-351
To evaluate the trend in the use of direct care in a cohort of nursing home (NH) residents and explore its association with resident characteristics and organizational factors. METHODS/DESIGN: A total of 696 NH residents from 47 Norwegian NHs were included at admissions at NH. In 537 residents, the use of direct care was assessed every 6 months over a course of 3 years. A multiple model was estimated to identify demographic, clinical, and organizational characteristics associated with the use of direct care time. RESULTS: Six months after admission, on average, 76.2 hours of direct care were rendered to each resident per month, while this number was reduced to 50.3 hours per month at the end of the study period. Most residents (92%) showed a stable use of direct care time, while a small group of residents displayed a much higher and varying use of direct care time. Increasing dementia, neuropsychiatric symptoms, and decreasing function in activities of daily living were associated with higher use of direct care time. Direct care time constituted about 50% of the staff’s working time. CONCLUSION: In Norwegian NHs, high use of direct care time was associated with younger age, more severe dementia, and severe neuropsychiatric symptoms. By identifying factors that impact on direct care time, preventive measures might be put in place to the benefit of the residents and possibly to improve resource use. Further research should explore the association between direct care time, quality of care, and the residents’ quality of life.

Keeping pace with the ebbs and flows in daily nursing home operations.
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R. Bekker, D. Moeke and B. Schmidt.
Health Care Manag Sci 2019 Jun;22(2):350-363
Nursing homes are challenged to develop staffing strategies that enable them to efficiently meet the healthcare demand of their residents. In this study, we investigate how demand for care and support fluctuates over time and during the course of a day, using demand data from three independent nursing home departments of a single Dutch nursing home. This demand data is used as input for an optimization model that provides optimal staffing patterns across the day. For the optimization we use a Lindley-type equation and techniques from stochastic optimization to formulate a Mixed-Integer Linear Programming (MILP) model. The impact of both the current and proposed staffing patterns, in terms of waiting time and service level, are investigated. The results show substantial improvements for all three departments both in terms of average waiting time as well as in 15 minutes service level. Especially waiting during rush hours is significantly reduced, whereas there is only a slight increase in waiting time during non-rush hours.

Evaluation of time and resources required for professional dental cleaning in nursing home residents.
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A. G. Barbe, H. E. Kottmann, D. Muller, et al.
Spec Care Dentist 2019 Mar;39(2):89-96
We aimed to describe time requirements and costs associated with professional dental cleaning (PDC) performed by a dental nurse in one German nursing home, and to reveal potential differences in required time for demented versus nondemented and mobile versus immobile residents. METHODS AND RESULTS: We performed a retrospective, cross-sectional analysis of treatment time and costs, including a transparent, easily adaptable path of action that allows implementation of PDC in nursing homes. Total mean (+/-SD) treatment time for one session per resident was documented, including differences in demented and immobile residents, and projected treatment costs (euro/$) per resident. We found no differences in required time for one PDC (37 +/- 11 minutes) in residents with or without dementia (P = 0.803) or, immobile versus mobile residents (P = 0.396). Mean projected treatment costs of PDC were euro14.98/$17.07 per resident per cleaning session, resulting in total costs of euro13.5 million ($15.4 million). CONCLUSION: Cognitive status and mobility does not affect the mean time required to perform PDC by a dental nurse in nursing home residents. Main cost factor is working time of dental staff; consumable supplies have less impact. Our data may stimulate to include PDC as initial step toward implementation of long-term oral hygiene strategies.

Effect of nurse staffing on rehospitalizations and emergency department visits among short-stay nursing home residents: A Cross-sectional study using the US Nursing Home Compare database.
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A. Min and H. C. Hong.
Geriatr Nurs 2019 Mar – Apr;40(2):160-165
The aim of this study was to examine the effect of nurse staffing on both rehospitalizations and emergency department emergency department visits among short-stay nursing home residents in the United States. Data for 11,132 US nursing homes were drawn from the 2016 Nursing Home Compare. We found that the Five-Star Quality Rating System’s staffing rating is a significant predictor for the rates of rehospitalization and emergency department visit among short-stay nursing home residents. The results also showed the importance of registered nurse staffing in nursing home caring for short-stay residents. Administrators and policy-makers can employ the findings to formulate management strategies that will reduce rehospitalizations and emergency department visits among nursing home residents.

Lying to patients with dementia: Attitudes versus behaviours in nurses.
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D. Cantone, F. Attena, S. Cerrone, et al.
Nurs Ethics 2019 Jun;26(4):984-992
Using lies, in dementia care, reveals a common practice far beyond the diagnosis and prognosis, extending to the entire care process. OBJECTIVES: In this article, we report results about the attitude and the behaviour of nurses towards the use of lies to patients with dementia. RESEARCH DESIGN: An epidemiological cross-sectional study was conducted between September 2016 and February 2017 in 12 elderly residential facilities and in the geriatric, psychiatric and neurological wards of six specialised hospitals of Italy’s Campania Region. PARTICIPANTS: In all, 106 nurses compiled an attitude questionnaire (A) where the main question was ‘Do you think it is ethically acceptable to use lies to patients with dementia?’, instead 106 nurses compiled a behaviour questionnaire (B), where the main question was ‘Have you ever used lies to patients with dementia?’ ETHICAL CONSIDERATIONS: Using lies in dementia care, although topic ethically still controversial, reveals a common practice far beyond the diagnosis and prognosis, extending to the entire care process. FINDINGS: Only a small percentage of the interviewed nurses stated that they never used lies/that it is never acceptable to use lies (behaviour 10.4% and attitude 12.3%; p = 0.66). The situation in which nurses were more oriented to use lies was ‘to prevent or reduce aggressive behaviors’. Indeed, only the 6.7% in the attitude group and 3.8% in the behaviour group were against using lies. On the contrary, the case in which the nurses were less oriented to use lies was ‘to avoid wasting time giving explanations’, in this situation were against using lies the 51.0% of the behaviour group and the 44.6% of the attitude group. CONCLUSION: Our results, according to other studies, support the hypothesis of a low propensity of nurses to ethical reflection about use of lies. In our country, the implementation of guidelines about a correct use of lie in the relationship between health operators and patients would be desirable.

Involving institutionalised people with dementia in their care-planning meetings: lessons learnt by the staff.
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F. Villar, M. Celdran, J. Vila-Miravent and R. Serrat.
Scand J Caring Sci 2018 Jun;32(2):567-574
Applying a person-centred care (PCC) approach is an aspiration for many services attending people with dementia (PwD). However, the implementation and assessment of PCC practices represent a challenge to health professionals. AIM: To evaluate the impact on staff of a programme aiming to involve people with dementia (PwD) in their individualised care-planning (ICP) meetings in long-term residential settings; specifically, to explore the lessons that staff perceived they had learned from the experience. METHODS: Twenty-one staff members working in residential facilities for older people were interviewed after the programme. Responses to two questions (‘Do you think that your work has been affected in any way by the attendance of PwD at ICP meetings?’ and ‘Have you learnt something new as a result of these meetings?’) were submitted to thematic analysis. RESULTS: Eighteen of the 21 participants identified at least one lesson they had learned from the experience. The lessons could be grouped under three main headings: (i) an increase in their understanding of PwD, (ii) questioning of their own care practices, and (iii) an improvement in teamwork. CONCLUSION: The involvement of PwD in ICP meetings had a positive impact on staff. They stated that the experience encouraged them to develop PCC-compatible attitudes and modify the way they treat PwD, thus improving the quality of care they deliver. The experience also seemed to empower staff (particularly the lesser trained members) and increase the cohesion of working teams.

‘That just breaks my heart’: Moral Concerns of Direct Care Workers Providing Palliative Care in LTC Homes
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E. Wiersma, J. Marcella, J. McAnulty and M. L. Kelley.
Can J Aging 2019 Sep;38(3):268-280
The literature on ethics in health care that explores the moral concerns of care providers typically focuses on registered health professionals and ethical dilemmas in acute and primary care. Far less attention has been paid to the long-term care (LTC) environment and non-registered, direct care workers. To address this gap, this research examined the moral concerns of personal support workers (PSWs) who provide direct care to residents. Data were collected during a 5-year participatory action research project to formalize palliative care programs in LTC homes. Eleven focus groups explored PSWs’ experiences providing palliative care in LTC homes, their challenges and learning needs (n = 45). In-depth secondary analysis of these focus groups found that PSWs experienced moral dilemmas. Two main moral dilemmas were ensuring that residents don’t die alone; and providing the appropriate care based on residents’ wishes. Their organizational constraints coalesced around policies, hierarchy, time, and balancing residents’ needs.

Dementia Care in Canada: Nursing Recommendations
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V. M. Boscart, S. McNeill and D. Grinspun.
Can J Aging 2019 Sep;38(3):407-418
The prevention and management of dementia in Canada is at a crossroads. Despite the low diagnosis rates, the number of persons living with dementia continues to increase. Yet, Canada’s health care policies have resulted in more people living with dementia living at home, and with most of their care being provided by family, friends, and significant others. This Policy Note provides an overview of a joint submission from the Canadian Gerontological Nursing Association (CGNA) and the Registered Nurses’ Association of Ontario (RNAO) to the Standing Senate Committee on Social Affairs, Science, and Technology. This article outlines the background and recommendations in five key areas of dementia care in Canada: health system resources, education and training of health providers, housing, care partners, and the integration of health and social supports. Based on these five key areas, a number of health and social policy interventions are discussed.

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Health Care Innovation and Quality Assurance

When Less is More, but Still Not Enough: Why Focusing on Limiting Antipsychotics in People With Dementia Is the Wrong Policy Imperative.
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H. C. Kales, L. N. Gitlin and C. G. Lyketsos.
J Am Med Dir Assoc 2019 Aug 6
Antipsychotic reductions have been the primary focus of efforts to improve dementia care in nursing homes by the Centers for Medicare & Medicaid Services National Partnership. Although significant antipsychotic reductions have been achieved, this policy focus is myopic in 2 ways; there is no evidence for any increases in use of nonpharmacologic interventions, and there are indications for compensatory increases in the use of other (unmeasured) sedating psychotropics. This increased use of other sedating psychotropics is more concerning than the antipsychotics that they replaced, as there is even less support of efficacy for behavioral and psychological symptoms of dementia (BPSD) and ample proof of harms, including mortality. The current paradigm of “assessment” and “treatment” for BPSD is largely cursory and reflexive, with little effort put forth to understand possible underlying causes. This contrasts with the methodical, evidence-based way the field handles other symptoms considered “medical” (eg, shortness of breath). To move beyond this nonmedical approach to BPSD, we suggest a conceptual model that includes putative causal contributors. Although at their core BPSD are caused by brain circuitry disruptions, such disruptions are theorized to increase the person with dementia’s vulnerability to 3 categories of triggers: those related to the (1) patient (eg, pain, hunger, and infection), (2) caregivers (eg, competing priorities, unrealistic expectations, and negative communications), and (3) environment (eg, overstimulation and limited light exposure). Assessing modifiable triggers is inherently person-centered as it enables clinicians to select specific nonpharmacologic strategies to mitigate identified triggers. Assessing triggers and selecting strategies, however, is time-intensive and reflects a paradigm shift necessitating a reorganization of dementia care including compensation for time spent elucidating and addressing modifiable triggers, vs unintendedly incentivizing the use of potentially harmful psychotropics. This paradigm shift should also include the measurement and restriction of any sedating medications for BPSD, particularly without assessment of underlying causes.

Deprescribing in Nursing Home Residents on Polypharmacy: Incidence and Associated Factors
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G. Onder, D. L. Vetrano, E. R. Villani, et al.
J Am Med Dir Assoc 2019 Mar 7
To assess 1-year incidence and factors related to deprescribing in nursing home (NH) residents in Europe. DESIGN: Longitudinal multicenter cohort study based on data from the Services and Health for Elderly in Long TERm care (SHELTER) study. SETTING: NHs in Europe and Israel. PARTICIPANTS: 1843 NH residents on polypharmacy. METHODS: Polypharmacy was defined as the concurrent use of 5 or more medications. Deprescribing was defined as a reduction in the number of medications used over the study period. Residents were followed for 12 months. RESULTS: Residents in the study sample were using a mean number of 8.6 (standard deviation 2.9) medications at the baseline assessment. Deprescribing was observed in 658 residents (35.7%). Cognitive impairment (mild/moderate impairment vs intact, odds ratio [OR] 1.41, 95% confidence interval [CI] 1.11-1.79; severe impairment vs intact, OR 1.60, 95% CI 1.23-2.09), presence of the geriatrician within the facility staff (OR 1.41, 95% CI 1.15-1.72), and number of medications used at baseline (OR 1.10, 95% CI 1.06-1.14) were associated with higher probabilities of deprescribing. In contrast, female gender (OR 0.76, 95% CI 0.61-0.96), heart failure (OR 0.69, 95% CI 0.53-0.89), and cancer (OR 0.64, 95% CI 0.45-0.90) were associated with a lower probability of deprescribing. CONCLUSIONS AND IMPLICATIONS: Deprescribing is common in NH residents on polypharmacy, and it is associated with individual and organizational factors. More evidence is needed on deprescribing, and clear strategies on how to withdraw medications should be defined in the future.

Advancing the Science of Deprescribing: A Novel Comprehensive Conceptual Framework.
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A. Linsky, W. F. Gellad, J. A. Linder and M. W. Friedberg.
J Am Geriatr Soc 2019 Aug 20
Polypharmacy is common in older adults and associated with inappropriate medication use, adverse drug events, medication nonadherence, higher costs, and increased mortality compared with those without polypharmacy. Deprescribing, the clinically supervised process of stopping or reducing the dose of medications when they cause harm or no longer provide benefit, may improve outcomes. Although potentially beneficial, clinicians struggle to overcome structural, organizational, technological, and cognitive barriers to deprescribing, limiting its use in clinical practice. Deprescribing science would benefit from a unifying conceptual framework to prioritize research. Current deprescribing conceptual frameworks have made important contributions to the field but often with a focus on specific medication classes or aspects of deprescribing. To further this relatively nascent field, we developed a broader deprescribing conceptual framework that builds on prior frameworks and includes patient, prescriber, and system influences; the process of deprescribing; outcomes; and dissemination. Patient factors include patients’ biology, experience, values, and preferences. Prescriber factors include rational (eg, based on explicit knowledge) and nonrational (eg, behavioral tendencies, biases, and heuristics) decision making. System factors include resources, incentives, goals, and culture that contribute to deprescribing. The framework separates the deprescribing decision from the deprescribing process. The framework captures the results of deprescribing by examining changes in clinical structures, performance processes, patient experience, health outcomes, and cost. Through testing and refinement, this novel, more comprehensive conceptual framework has the potential to advance deprescribing research by organizing the existing evidence, identifying evidence gaps, and categorizing deprescribing interventions and the settings in which they are applied.

Emotional Expression of Persons with Dementia: An Integrative Review with Implications for Evidence-Based Practice.
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K. H. Lee, J. Y. Lee, M. Boltz and E. S. McConnell.
Worldviews Evid Based Nurs 2019 Aug 9
The ability to express emotion typically is preserved longer than language and cognitive function in persons living with dementia. Emotional expression may be an important indicator of underlying individual needs and feelings and may therefore facilitate person-centered care. AIMS: This review aimed to examine how emotional expression has been described, measured, and utilized in empirical studies. METHODS: The design of this study was an integrative literature review. A systematic search was conducted through electronic databases using defined search terms. Articles published up to March 2018 were included. The method proposed by Whittemore and Knafl was used for data synthesis and review integration. Quality appraisal of the selected articles was evaluated by the Mixed Methods Assessment Tool. RESULTS: Most of the articles used feeling-related terms without specific definitions. Less frequently, terms such as affect, emotion, and mood were defined. Although these terms were used interchangeably in the articles, affect, which was defined as expressed emotion in general, was a comprehensive term to encompass other terms. Measurement of emotional expression was performed using observational methods, with direct observation or video recording using a hand-held camera. In both cases, observed emotion was coded with diverse methods or tools. In studies, the emotional expression was utilized as (a) an outcome to demonstrate the effect of interventions, (b) a factor to show relationship with other variables, or (c) an observed value itself. LINKING EVIDENCE TO ACTION: This review provides insights about measurement options for emotional expressions among persons with dementia in long-term care. Long-term care staff should pay attention to emotional expression of persons with dementia to understand underlying unmet needs. Development of adequate measurement of emotional expression could facilitate development of emotion-oriented intervention program to improve psychological well-being and the behavioral and functional health of persons living with dementia.

Graphic designed bedroom doors to support dementia wandering in residential care homes: Innovative practice
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A. L. Varshawsky and V. Traynor.
Dementia (London) 2019 Aug 7:1471301219868619.
Dementia-friendly designs are important in residential care homes but an aspect that remains neglected is the potential role of door designs in promoting wayfinding. A pilot project in NSW, Australia, tested the effects of unique room door designs for a small group of individuals living with dementia in a residential care home. Internal doors were transformed using a giant adhesive poster created by a commercial graphic designer. The poster replicated the look of traditional front doors, including a range of bright bold colours and architectural features, such as brass doorknockers, letterboxes and door guards. The Revised Algase Wandering Scale (RAWS) was used to identify the effects of introducing the doors on persistent walking, eloping behaviours and spatial disorientation. A total of nine individuals living with dementia participated in the project. The post-intervention data demonstrated that there was a reduction in persistent walking, eloping behaviours and spatial disorientation. In addition, ongoing anecdotal evidence found that individuals continued to seek out others to showcase their unique door.

Improving the normalization of complex interventions: part 1 – development of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT).
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T. Rapley, M. Girling, F. S. Mair, et al.
BMC Med Res Methodol 2018 Nov 15;18(1):133-018-0590-y
Understanding and measuring implementation processes is a key challenge for implementation researchers. This study draws on Normalization Process Theory (NPT) to develop an instrument that can be applied to assess, monitor or measure factors likely to affect normalization from the perspective of implementation participants. METHODS: An iterative process of instrument development was undertaken using the following methods: theoretical elaboration, item generation and item reduction (team workshops); item appraisal (QAS-99); cognitive testing with complex intervention teams; theory re-validation with NPT experts; and pilot testing of instrument. RESULTS: We initially generated 112 potential questionnaire items; these were then reduced to 47 through team workshops and item appraisal. No concerns about item wording and construction were raised through the item appraisal process. We undertook three rounds of cognitive interviews with professionals (n = 30) involved in the development, evaluation, delivery or reception of complex interventions. We identified minor issues around wording of some items; universal issues around how to engage with people at different time points in an intervention; and conceptual issues around the types of people for whom the instrument should be designed. We managed these by adding extra items (n = 6) and including a new set of option responses: ‘not relevant at this stage’, ‘not relevant to my role’ and ‘not relevant to this intervention’ and decided to design an instrument explicitly for those people either delivering or receiving an intervention. This version of the instrument had 53 items. Twenty-three people with a good working knowledge of NPT reviewed the items for theoretical drift. Items that displayed a poor alignment with NPT sub-constructs were removed (n = 8) and others revised or combined (n = 6). The final instrument, with 43 items, was successfully piloted with five people, with a 100% completion rate of items. CONCLUSION: The process of moving through cycles of theoretical translation, item generation, cognitive testing, and theoretical (re)validation was essential for maintaining a balance between the theoretical integrity of the NPT concepts and the ease with which intended respondents could answer the questions. The final instrument could be easily understood and completed, while retaining theoretical validity. NoMAD represents a measure that can be used to understand implementation participants’ experiences. It is intended as a measure that can be used alongside instruments that measure other dimensions of implementation activity, such as implementation fidelity, adoption, and readiness.

Improving the normalization of complex interventions: part 2 – validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT).
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T. L. Finch, M. Girling, C. R. May, et al.
BMC Med Res Methodol 2018 Nov 15;18(1):135-018-0591-x
Successful implementation and embedding of new health care practices relies on co-ordinated, collective behaviour of individuals working within the constraints of health care settings. Normalization Process Theory (NPT) provides a theory of implementation that emphasises collective action in explaining, and shaping, the embedding of new practices. To extend the practical utility of NPT for improving implementation success, an instrument (NoMAD) was developed and validated. METHODS: Descriptive analysis and psychometric testing of an instrument developed by the authors, through an iterative process that included item generation, consensus methods, item appraisal, and cognitive testing. A 46 item questionnaire was tested in 6 sites implementing health related interventions, using paper and online completion. Participants were staff directly involved in working with the interventions. Descriptive analysis and consensus methods were used to remove redundancy, reducing the final tool to 23 items. Data were subject to confirmatory factor analysis which sought to confirm the theoretical structure within the sample. RESULTS: We obtained 831 completed questionnaires, an average response rate of 39% (range: 22-77%). Full completion of items was 50% (n = 413). The confirmatory factor analysis showed the model achieved acceptable fit (CFI = 0.95, TLI = 0.93, RMSEA = 0.08, SRMR = 0.03). Construct validity of the four theoretical constructs of NPT was supported, and internal consistency (Cronbach’s alpha) were as follows: Coherence (4 items, alpha = 0.71); Collective Action (7 items, alpha = 0.78); Cognitive Participation (4 items, alpha = 0.81); Reflexive Monitoring (5 items, alpha = 0.65). The normalisation scale overall, was highly reliable (20 items, alpha = 0.89). CONCLUSIONS: The NoMAD instrument has good face validity, construct validity and internal consistency, for assessing staff perceptions of factors relevant to embedding interventions that change their work practices. Uses in evaluating and guiding implementation are proposed.

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Research Practice and Methodology

Modeling the Economic Impact of Interventions for Older Populations with Multimorbidity: A Method of Linking Multiple Single-Disease Models.
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J. H. Youn, M. D. Stevenson, P. Thokala, K. Payne and M. Goddard.
Med Decis Making 2019 Aug 20:272989X19868987
Individuals from older populations tend to have more than 1 health condition (multimorbidity). Current approaches to produce economic evidence for clinical guidelines using decision-analytic models typically use a single-disease approach, which may not appropriately reflect the competing risks within a population with multimorbidity. This study aims to demonstrate a proof-of-concept method of modeling multiple conditions in a single decision-analytic model to estimate the impact of multimorbidity on the cost-effectiveness of interventions. Methods. Multiple conditions were modeled within a single decision-analytic model by linking multiple single-disease models. Individual discrete event simulation models were developed to evaluate the cost-effectiveness of preventative interventions for a case study assuming a UK National Health Service perspective. The case study used 3 diseases (heart disease, Alzheimer’s disease, and osteoporosis) that were combined within a single linked model. The linked model, with and without correlations between diseases incorporated, simulated the general population aged 45 years and older to compare results in terms of lifetime costs and quality-adjusted life-years (QALYs). Results. The estimated incremental costs and QALYs for health care interventions differed when 3 diseases were modeled simultaneously ( pound840; 0.234 QALYs) compared with aggregated results from 3 single-disease models ( pound408; 0.280QALYs). With correlations between diseases additionally incorporated, both absolute and incremental costs and QALY estimates changed in different directions, suggesting that the inclusion of correlations can alter model results. Discussion. Linking multiple single-disease models provides a methodological option for decision analysts who undertake research on populations with multimorbidity. It also has potential for wider applications in informing decisions on commissioning of health care services and long-term priority setting across diseases and health care programs through providing potentially more accurate estimations of the relative cost-effectiveness of interventions.

Research, recruitment and observational data collection in care homes: lessons from the PACE study.
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D. Collingridge Moore, S. Payne, L. Van den Block, et al.
BMC Res Notes 2019 Aug 14;12(1):508-019-4543-2
Care homes are a common place of death for older adults, especially those with complex health needs or dementia. Representative, internationally comparable data on care home facilities and their residents is needed to monitor health and wellbeing in this population. Identification and collection of data from care homes can be challenging and often underreported. This paper draws on the experiences of the PACE study, a cross sectional mortality follow back study conducted in six European countries. RESULTS: Multiple challenges were encountered in creating a sampling framework and contacting, recruiting and retaining care homes in the PACE study. Recruiting a randomly identified, representative cohort from a stratified sampling framework was problematic, as was engaging with care homes to ensure high response rates. Variation in the funding of care homes across the six countries involved in the study may explain the additional challenges encountered in England. Awareness of the challenges encountered in England in implementing an international study in care homes can inform the design and implementation of future studies within care homes. Further discussion is needed to determine the barriers and facilitators to conducting research in care homes, and how this is shaped by the focus of the study.

End-Users and Caregivers’ Involvement in Health Interventional Research Carried Out in Geriatric Facilities: A Systematic Review.
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M. Ahouah and M. Rothan-Tondeur.
Int J Environ Res Public Health 2019 Aug 7;16(16):10.3390/ijerph16162812
Public involvement (PI) is of great interest. However, little is known about this topic in the design, development, and/or implementation of health interventions in geriatric facilities. This study aimed to provide a critical overview of the involvement of caregivers and end-users in interventions in these facilities, based on Rifkin’s analytical framework. This systematic review, supplemented by a questionnaire to the corresponding authors, covered non-drug intervention reports targeting nurses, doctors, residents, and their relatives. Articles were published in Pubmed, Medline, Scopus, and Cinahl, from January 2016 to April 2018. Ninety-seven articles were included. The review shows a low level or partial PI in geriatric facilities where it exists. These results are further supported by the authors’ responses to the questionnaire. PI remains uncommon in geriatric institutions and consists of a consumerist model, suggesting the need for improved practices. More efforts are needed to experiment with recommendations to meet the challenges of PI and enhance the public ownership of interventions. The protocol was registered on Prospero under the number CRD42018098504.

Evidence of commitment to research partnerships?
Results of two web reviews

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D. de Moissac, S. Bowen, I. Botting, et al.
Health Res Policy Syst 2019 Jul 30;17(1):73-019-0475-5
Partnerships between academic researchers and health system leadership are often promoted by health research funding agencies as an important strategy in helping ensure that funded research is relevant and the results used. While potential benefits of such partnerships have been identified, there is limited guidance in the scientific literature for either healthcare organisations or researchers on how to select, build and manage effective research partnerships. Our main research objective was to explore the health system perspective on partnerships with researchers with a focus on issues related to the design and organisation of the health system and services. Two structured web reviews were conducted as one component of this larger study. METHODS: Two separate structured web reviews were conducted using structured data extraction tools. The first review focused on sites of health research bodies and those providing information on health system management and knowledge translation (n = 38) to identify what guidance to support partnerships might be available on websites commonly accessed by health leaders and researchers. The second reviewed sites from all health ‘regions’ in Canada (n = 64) to determine what criteria and standards were currently used in guiding decisions to engage in research partnerships; phone follow-up ensured all relevant information was collected. RESULTS: Absence of guidance on partnerships between research institutions and health system leaders was found. In the first review, absence of guidance on research partnerships and knowledge coproduction was striking and in contrast with coverage of other forms of collaboration such as patient/community engagement. In the second review, little evidence of criteria and standards regarding research partnerships was found. Difficulties in finding appropriate contact information for those responsible for research and obtaining a response were commonly experienced. CONCLUSION: Guidance related to health system partnerships with academic researchers is lacking on websites that should promote and support such collaborations. Health region websites provide little evidence of partnership criteria and often do not make contact information to research leaders within health systems readily available; this may hinder partnership development between health systems and academia.

Between relevance and excellence? Research impact agenda and the production of policy knowledge
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Justyna Bandola-Gill.
spp 2019 08/01; 8/24
The recent moves towards incentivising “impact” within the research funding system pose a growing challenge to academic research practices, charged with producing both scientific, and social impact. This article explores this tension by drawing on interviews with sixty-one UK academics and policymakers involved in publicly-funded knowledge exchange initiatives. The experiences of the interviewed academics point to a functional separation of academic practices into three distinct types: producing traditional research, translating research, and producing policy-oriented research. These three types of practices differ in terms of both the epistemic qualities of the produced knowledge and its legitimacy as valid academic work. Overall, the article argues that the relationship between relevance and excellence of research within the impact agenda is characterised by simultaneous contradiction and co-dependence, leading to hybridisation of academic knowledge production and expansion of the boundaries of policy expertise into the traditionally-academic spaces.

Qualitative Evidence Synthesis (QES) for Guidelines: Paper 1 – Using qualitative evidence synthesis to inform guideline scope and develop qualitative findings statements.
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S. Downe, K. W. Finlayson, T. A. Lawrie, et al.
Health Res Policy Syst 2019 Aug 8;17(1):76-019-0467-5
WHO has recognised the need to ensure that guideline processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. Along with decision-making criteria that require findings from effectiveness reviews, WHO is increasingly using evidence derived from qualitative evidence syntheses (QES) to inform the values, acceptability, equity and feasibility implications of its recommendations. This is the first in a series of three papers examining the use of QES in developing clinical and health systems guidelines. METHODS: WHO convened a group of methodologists involved in developing recent (2010-2018) guidelines that were informed by QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. Our aim in this paper is to (1) describe and discuss how the findings of QES can inform the scope of a guideline and (2) develop findings for key guideline decision-making criteria. RESULTS: QES resulted in the addition of new outcomes that are directly relevant to service users, a stronger evidence base for decisions about how much effective interventions and related outcomes are valued by stakeholders in a range of contexts, and a more complete database of summary evidence for guideline panels to consider, linked to decisions about values, acceptability, feasibility and equity. CONCLUSIONS: Rigorously conducted QES can be a powerful means of improving the relevance of guidelines, and of ensuring that the concerns of stakeholders, at all levels of the healthcare system and from a wide range of settings, are taken into account at all stages of the process.

Qualitative Evidence Synthesis (QES) for Guidelines: Paper 2 – Using qualitative evidence synthesis findings to inform evidence-to-decision frameworks and recommendations
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S. Lewin, C. Glenton, T. A. Lawrie, et al.
Health Res Policy Syst 2019 Aug 8;17(1):75-019-0468-4
WHO has recognised the need to improve its guideline methodology to ensure that guideline decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. To help achieve this, WHO guidelines now typically enhance intervention effectiveness data with evidence on a wider range of decision-making criteria, including how stakeholders value different outcomes, equity, gender and human rights impacts, and the acceptability and feasibility of interventions. Qualitative evidence syntheses (QES) are increasingly used to provide evidence on this wider range of issues. In this paper, we describe and discuss how to use the findings from QES to populate decision-making criteria in evidence-to-decision (EtD) frameworks. This is the second in a series of three papers that examines the use of QES in developing clinical and health system guidelines. METHODS: WHO convened a writing group drawn from the technical teams involved in its recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. RESULTS: We describe a step-wise approach to populating EtD frameworks with QES findings. This involves allocating findings to the different EtD criteria (how stakeholders value different outcomes, equity, acceptability and feasibility, etc.), weaving the findings into a short narrative relevant to each criterion, and inserting this summary narrative into the corresponding ‘research evidence’ sections of the EtD. We also identify areas for further methodological research, including how best to summarise and present qualitative data to groups developing guidelines, how these groups draw on different types of evidence in their decisions, and the extent to which our experiences are relevant to decision-making processes in fields other than health. CONCLUSIONS: This paper shows the value of incorporating QES within a guideline development process, and the roles that qualitative evidence can play in integrating the views and experiences of relevant stakeholders, including groups who may not be otherwise represented in the decision-making process.

Qualitative Evidence Synthesis (QES) for Guidelines: Paper 3 – Using qualitative evidence syntheses to develop implementation considerations and inform implementation processes
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C. Glenton, S. Lewin, T. A. Lawrie, et al.
Health Res Policy Syst 2019 Aug 8;17(1):74-019-0450-1
This is the third in a series of three papers describing the use of qualitative evidence syntheses (QES) to inform the development of clinical and health systems guidelines. WHO has recognised the need to improve its guideline methodology to ensure that decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable to end users. In addition to the standard data on effectiveness, WHO guidelines increasingly use evidence derived from QES to provide information on acceptability and feasibility and to develop important implementation considerations. METHODS: WHO convened a group drawn from the technical teams involved in formulating recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. As members of WHO guideline technical teams, our aim in this paper is to explore how we have used findings from QES to develop implementation considerations for these guidelines. RESULTS: For each guideline, in addition to using systematic reviews of effectiveness, the technical teams used QES to gather evidence of the acceptability and feasibility of interventions and, in some cases, equity issues and the value people place on different outcomes. This evidence was synthesised using standardised processes. The teams then used the QES to identify implementation considerations combined with other sources of information and input from experts. CONCLUSIONS: QES were useful sources of information for implementation considerations. However, several issues for further development remain, including whether researchers should use existing health systems frameworks when developing implementation considerations; whether researchers should take confidence in the evidence into account when developing implementation considerations; whether qualitative evidence that reveals implementation challenges should lead guideline panels to make conditional recommendations or only point to implementation considerations; and whether guideline users find it helpful to have challenges pointed out to them or whether they also need solutions. Finally, we need to explore how QES findings can be incorporated into derivative products to aid implementation.

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Aging

Modeling Factors of Urinary Incontinence in Institutional Older Adults with Dementia.
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H. C. Li, K. M. Chen and H. F. Hsu.
J Clin Nurs 2019 Aug 20
This study applied structural equation modeling to explore the relationships among agitated behaviors, depression, cognitive function, and activities of daily living (ADL), as well as associations between these factors and urinary incontinence (UI). BACKGROUND: A high prevalence of UI is found among institutional older adults with dementia. People with UI suffer from increased financial burden and social isolation and experience reduced quality of life. DESIGN: Cross-sectional, correlational research. The study complied with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. METHODS: In total, 226 older adults with dementia were recruited through convenience sampling at 15 long-term care facilities in southern Taiwan. The UI frequency, agitated behaviors, depression, cognitive function, and ADL were evaluated using bladder records, the Cohen-Mansfield Agitation Inventory (CMAI), the Cornell Scale for Depression in Dementia (CSDD), the Mini-Mental State Examination (MMSE), and the Barthel Index (BI), respectively. RESULTS: ADL performance was found to be significantly associated with UI; however, age, cognitive function, depression, and agitated behaviors were not significantly related to UI. Age did not have effects on any of the variables tested in this model, whereas ADL performance was significantly associated with cognitive function and depression. Results further showed that cognitive function and depression were mediators between ADL and agitated behaviors. CONCLUSION: Enhanced ADL independency directly reduced UI, improved cognitive function, decreased degrees of depression, and indirectly reduced agitated behaviors. RELEVANCE TO CLINICAL PRACTICE: The findings could serve as a valuable reference for long-term care facilities in providing effective urinary incontinence care and prevention to older adults with dementia. This article is protected by copyright. All rights reserved.

Next of kin’s quality of life before and after implementation of a knowledge-based palliative care intervention in nursing homes.
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C. Bokberg, L. Behm and G. Ahlstrom.
Qual Life Res 2019 Aug 14
The purpose of this study was to evaluate whether an educational palliative care intervention improved the quality of life for next of kin to older persons in nursing homes. METHODS: Altogether, 90 next of kin in the intervention group and 105 next of kin in the control group were included. Data were collected using the WHOQOL-BREF questionnaire, answered before and 3 months after the intervention was completed. Descriptive and comparative analyses were performed. RESULTS: This study found a statistically significant increase in the Physical health subscale in the intervention group but not in the control group. In contrast, the General health score decreased in the control group but not in the implementation group. Furthermore, we found an increase in the item able to perform activities of daily living in the intervention group and a decrease in the item energy and fatigue in the control group. CONCLUSION: The results indicated small statistical changes regarding next of kins’ QoL in favour of the intervention. Lessons learned from the study for future research are to include next of kin as participants at meetings about next of kin and to include more meetings about the theme next of kin. Both approaches would bring a stronger focus on the family-centred care aspect of the intervention into the education component, which this study indicates the need for. TRIAL REGISTRY: Trial registration NCT02708498. Date of registration 26 February 2016.

Health status of care home residents: practicality and construct validity of data collection by staff at scale.
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T. Benson and C. Bowman.
BMJ Open Qual 2019 Jul 26;8(3):e000704-2019-000704. eCollection 2019
Medical diagnoses and assessed need for care are the prerequisites for planning and delivery of care to residents of care homes. Assessing the effectiveness of care is difficult. The aim of this study was to test the practicality and construct validity of the howRu health status measure using secondary analysis of a large data set. Method: The data came from a Bupa Care Homes Census in 2012, which covered 24 506 residents in 395 homes internationally (UK, Australia and New Zealand). Staff completed optical mark readable forms about each resident using a short generic health status measure, howRu. Response rates were used to assess practicality and expected relationships between health status and independent variables were used to assess the construct validity. Results and discussion: 19,438 forms were returned (79.3%) in 360 care homes (91.1%); complete health status data were recorded for 18 617 residents (95.8% of those returned). Missing values for any health status items mostly came from a small number of homes. The relationships between howRu and independent variables support construct validity. Factor analysis suggests three latent variables (discomfort, distress and disability/dependence). Conclusions: HowRu proved easy to use and practical at scale. The howRu health status measure shows good construct validity.

Features and impact of missing values in the association of self-rated health with mortality in care homes: a longitudinal study.
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M. D. P. Rodriguez-Garcia, A. Ayala, C. Rodriguez-Blazquez, P. Martinez-Martin, M. J. Forjaz and J. Damian.
Health Qual Life Outcomes 2019 Jun 29;17(1):111-019-1184-z
Self-rated health (SRH) is a health measure used in studies of older adults. The objective of this study is to analyze SRH as a predictor of mortality in the institutionalized older population and the characteristics of those who do not provide information about their SRH on health questionnaires. METHODS: This is a 15-year follow-up study of older adult residents in nursing or care homes in of Madrid, Spain. SRH was measured on a 5-point Likert type scale. The association between answering the SRH question and socio-demographic and health characteristics was evaluated through prevalence ratio (PR), estimated by Poisson regression models. Survival rates associated with SRH were studied through a multivariate Cox regression. RESULTS: The sample has a mean age of 83.4 (standard deviation, SD = 7.3), with 75.7% women. Twelve percent did not answer the SRH item. Those who did not answer showed a higher probability of disability (Barthel index, PR = 0.76, 95% confidence interval = 0.67-0.86) and/or dementia (PR = 8.03, 3.38-19.03). A trend for higher mortality was observed in those persons who did not respond (adjusted hazard ratio HR = 1.26, 0.75-2.11). The mortality rate was 32% higher for those who declared poor SRH in comparison with those who reported good SRH (adjusted HR = 1.32, 1.08-1.6). CONCLUSIONS: There is an elevated number of people who do not respond to the SRH item, mainly those with disabilities and cognitive deterioration. Lack of response to SRH is a good indicator of 15-year mortality for persons institutionalized in care or nursing homes.

Young-onset dementia and the need for specialist care: a national and international perspective.
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J. E. Carter, J. R. Oyebode and R. T. C. M. Koopmans.
Aging Ment Health 2018 Apr;22(4):468-473
Receiving a timely and accurate diagnosis and gaining access to age-appropriate support for younger people living with dementia (YPD) remains a challenge both in the UK and internationally because the focus of most dementia services is primarily upon the needs of older people. The political case to improve services for YPD depends upon the establishment of an understanding of the clinical symptoms, an unequivocal evidence base about need and an accurate evaluation of the size of the population affected. This short report assesses the evidence base from international studies regarding service design and delivery. The goal is to raise awareness, advance best practice and galvanise the international community to address the serious underfunding and underprovision of care for this marginalised group. CONCLUSION: The current evidence suggests that there are universal problems, regardless of continent, with delays to diagnosis and poor understanding of optimum models for service provision and long-term care.

Relevant factors of depression in dementia modifiable by non-pharmacotherapy: a systematic review.
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Y. Kubo, H. Hayashi, S. Kozawa and S. Okada.
Psychogeriatrics 2019 Mar;19(2):181-191
Depression in dementia patients is associated with complications such as decreased activities of daily living and decreased quality of life. Because pharmacotherapeutic treatments for depression in dementia patients may have a poor risk-benefit ratio, effective non-pharmacotherapeutic interventions are favourable. However, the development of effective treatments requires the identification of depression-associated factors that can be modified by non-pharmacotherapeutic means in dementia patients. This systematic literature review aimed to identify modifiable factors related to depression and confirm that these factors can be improved by non-pharmacotherapeutic interventions. We searched PubMed, SpringerLink, the Web of Science, and the Cochrane Library for articles published between June 2007 and June 2017. We included studies that investigated causes of depression in dementia patients and excluded studies with unclear dementia diagnostic criteria or operational definitions. Of 9004 records screened, 6 studies were included. The participants included community-dwelling individuals and long-term care facility residents. The severity of dementia varied from mild to severe. After reviewing the studies, we identified five modifiable relevant factors in community-dwelling individuals: (i) pain; (ii) neuropsychiatric symptoms; (iii) cognitive decline; (iv) social isolation; and (v) quality of life. In long-term care facility residents, we identified neuropsychiatric symptoms and quality of life as relevant factors. Our results indicated that non-pharmacological interventions that improve these factors may improve symptoms of depression. A longitudinal study is recommended to clarify the mechanisms underlying depression symptoms and treatment in dementia patients. In addition, further investigation is needed to elucidate the ways in which differing dementia types and severity affect symptoms of depression.

Hearing loss and its impact on residents in long term care facilities: A systematic review of literature.
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R. Punch and L. Horstmanshof.
Geriatr Nurs 2019 Mar – Apr;40(2):138-147
The prevalence of age-related hearing loss is high among older adults. Growing longevity and the older profile of aged care residents is likely to result in an increasing incidence of hearing loss among this cohort. This review reports on the findings of a systematic search of the academic databases CINAHL, Medline, PsychInfo and Scopus undertaken to investigate the hearing experiences of residents of aged care facilities. Twenty-two studies met the inclusion criteria. Our analysis revealed clear barriers and facilitators to optimal hearing experiences and indicated the importance of the physical and social environment for effective communication. Under-detection of hearing loss and underuse of hearing aids were prevalent. The findings highlight the importance of addressing these issues for this cohort’s quality of life. Future trends that may impact on training needs are considered and recommendations are made.

Pain Assessments in MDS 3.0: Agreement with Vital Sign Pain Records of Nursing Home Residents.
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Y. J. Wei, L. Solberg, C. Chen, et al.
J Am Geriatr Soc 2019 Aug 12.
The minimum data set (MDS) 3.0 implemented on October 1, 2010, is the latest version of a federally mandated clinical instrument used in Medicare‐ and Medicaid‐certified nursing homes. Improving on the 2.0 version, MDS 3.0 collects self‐assessments of pain from residents who can communicate verbally through a standardized resident interview.1 MDS 3.0 pain has an excellent nurse‐to‐nurse interrater reliability and expert content validity. However, it remains unclear to what extent the MDS 3.0 pain assessment adequately represents the clinical pain experience of nursing home residents. This study aims to examine the agreement between MDS 3.0 pain assessment and vital sign pain records documented during geriatrics’ ward visits.

Stakeholder perspectives of care for people living with dementia moving from hospital to care facilities in the community: a systematic review.
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A. Richardson, A. Blenkinsopp, M. Downs and K. Lord.
BMC Geriatr 2019 Jul 31;19(1):202-019-1220-1
People living with dementia in care homes are regularly admitted to hospital. The transition between hospitals and care homes is an area of documented poor care leading to adverse outcomes including costly re-hospitalisation. This review aims to understand the experiences and outcomes of care for people living with dementia who undergo this transition from the perspectives of key stakeholders; people living with dementia, their families and health care professionals. METHODS: A systematic search was conducted on the CINAHL, ASSIA, EMBASE, MEDLINE, PsychINFO, and Scopus databases without any date restrictions. We hand searched reference lists of included papers. Papers were included if they focused on people living with dementia moving from hospital to a short or long term care setting in the community including sub-acute, rehabilitation, skilled nursing facilities or care homes. Titles, abstracts and full texts were screened. Two authors independently evaluated study quality using a checklist. Themes were identified and discussed to reach consensus. RESULTS: In total, nine papers reporting eight studies met the inclusion criteria for the systematic review. A total of 257 stakeholders participated; 37 people living with dementia, 95 family members, and 125 health and social care professionals. Studies took place in Australia, Canada, United Kingdom (UK), and the United States of America (US). Four themes were identified as factors influencing the experience and outcomes of the transition from the perspectives of stakeholders; preparing for transition; quality of communication; the quality of care; family engagement and roles. CONCLUSION: This systematic review presents a compelling case for the need for robust evidence to guide best practice in this important area of multi-disciplinary clinical practice. The evidence suggests this transition is challenging for all stakeholders and that people with dementia have specific needs which need attention during this period. TRIAL REGISTRATION: PROSPERO Registration Number: CRD42017082041 .

The evidence for services to avoid or delay residential aged care admission: a systematic review
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J. A. Luker, A. Worley, M. Stanley, J. Uy, A. M. Watt and S. L. Hillier.
BMC Geriatr 2019 Aug 8;19(1):217-019-1210-3
Interventions that enable people to remain in their own home as they age are of interest to stakeholders, yet detailed information on effective interventions is scarce. Our objective was to systematically search and synthesise evidence for the effectiveness of community-based, aged care interventions in delaying or avoiding admission to residential aged care. METHOD: Nine databases were searched from January 2000 to February 2018 for English publications. Reference lists of relevant publications were searched. The databases yielded 55,221 citations and 50 citations were gleaned from other sources. Where there was sufficient homogeneity of study design, population, intervention and measures, meta-analyses were performed. Studies were grouped by the type of intervention: complex multifactorial interventions, minimal/single focus interventions, restorative programs, or by the target population (e.g. participants with dementia). RESULTS: Data from 31 randomised controlled trials (32 articles) that met our inclusion criteria were extracted and analysed. Compared to controls, complex multifactorial interventions in community aged care significantly improved older adults’ ability to remain living at home (risk difference – 0.02; 95% CI -0.03, – 0.00; p = 0.04). Commonalities in the 13 studies with complex interventions were the use of comprehensive assessment, regular reviews, case management, care planning, referrals to additional services, individualised interventions, frequent client contact if required, and liaison with General Practitioners. Complex interventions did not have a significantly different effect on mortality. Single focus interventions did not show a significant effect in reducing residential aged care admissions (risk difference 0, 95% CI -0.01, 0.01; p = 0.71), nor for mortality or quality of life. Subgroup analysis of complex interventions for people with dementia showed significant risk reduction for residential aged care admissions (RD -0.05; 95% CI -0.09, -0.01; p = 0.02). Compared to controls, only interventions targeting participants with dementia had a significant effect on improving quality of life (SMD 3.38, 95% CI 3.02, 3.74; p < 0.000001). CONCLUSIONS: Where the goal is to avoid residential aged care admission for people with or without dementia, there is evidence for multifactorial, individualised community programs. The evidence suggests these interventions do not result in greater mortality and hence are safe. Minimal, single focus interventions will not achieve the targeted outcomes. TRIAL REGISTRATION: PROSPERO Registration CRD42016050086

The burden of respiratory infections among older adults in long-term care: a systematic review
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A. Childs, A. R. Zullo, N. R. Joyce, et al.
BMC Geriatr 2019 Aug 5;19(1):210-019-1236-6
Respiratory infections among older adults in long-term care facilities (LTCFs) are a major global concern, yet a rigorous systematic synthesis of the literature on the burden of respiratory infections in the LTCF setting is lacking. To address the critical need for evidence regarding the global burden of respiratory infections in LTCFs, we assessed the burden of respiratory infections in LTCFs through a systematic review of the published literature. METHODS: We identified articles published between April 1964 and March 2019 through searches of PubMed (MEDLINE), EMBASE, and the Cochrane Library. Experimental and observational studies published in English that included adults aged >/=60 residing in LTCFs who were unvaccinated (to identify the natural infection burden), and that reported measures of occurrence for influenza, respiratory syncytial virus (RSV), or pneumonia were included. Disagreements about article inclusion were discussed and articles were included based on consensus. Data on study design, population, and findings were extracted from each article. Findings were synthesized qualitatively. RESULTS: A total of 1451 articles were screened for eligibility, 345 were selected for full-text review, and 26 were included. Study population mean ages ranged from 70.8 to 90.1 years. Three (12%) studies reported influenza estimates, 7 (27%) RSV, and 16 (62%) pneumonia. Eighteen (69%) studies reported incidence estimates, 7 (27%) prevalence estimates, and 1 (4%) both. Seven (27%) studies reported outbreaks. Respiratory infection incidence estimates ranged from 1.1 to 85.2% and prevalence estimates ranging from 1.4 to 55.8%. Influenza incidences ranged from 5.9 to 85.2%. RSV incidence proportions ranged from 1.1 to 13.5%. Pneumonia prevalence proportions ranged from 1.4 to 55.8% while incidence proportions ranged from 4.8 to 41.2%. CONCLUSIONS: The reported incidence and prevalence estimates of respiratory infections among older LTCF residents varied widely between published studies. The wide range of estimates offers little useful guidance for decision-making to decrease respiratory infection burden. Large, well-designed epidemiologic studies are therefore still necessary to credibly quantify the burden of respiratory infections among older adults in LTCFs, which will ultimately help inform future surveillance and intervention efforts.

Adverse Events in Long-term Care Residents Transitioning From Hospital Back to Nursing Home.
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A. Kapoor, T. Field, S. Handler, et al.
JAMA Intern Med 2019 Jul 22
Transition from hospital to nursing home is a high-risk period for adverse events in long-term care (LTC) residents. Adverse events include harms from medical care, including failure to provide appropriate care. Objective: To report the incidence, type, severity, and preventability of adverse events in LTC residents transitioning from hospital back to the same LTC facility. Design, Setting, and Participants: Prospective cohort study of LTC residents discharged from hospital back to LTC from March 1, 2016, to December 31, 2017, and followed up for 45 days. In a random sample of 32 nursing homes located in 6 New England states, 555 LTC residents were selected, contributing 762 transitions from hospital back to the same LTC facility. Main Outcomes and Measures: The main outcome was an adverse event within the 45-day period after transition from hospital back to nursing home. Trained nurse abstractors reviewed nursing home records for the period, and then 2 physicians independently reviewed each potential adverse event to determine whether harm occurred and to characterize the type, severity, and preventability of each event. When reviewers disagreed, they met to reach consensus. Results: Of the 555 individual residents, 365 (65.6%) were female, and the mean (SD) age at the time of discharge was 82.2 (11.5) years. Five hundred twenty (93.7%) were non-Hispanic white, 21 (3.8%) were non-Hispanic black, 9 (1.6%) were Hispanic, and 5 (0.9%) were of other non-Hispanic race/ethnicity. In the cohort, there were 379 adverse events among 762 discharges. One hundred ninety-seven events (52.0%) related to resident care, with pressure ulcers, skin tears, and falls with injury representing the most common types of events in this category. Health care-acquired infections (108 [28.5%]) and adverse drug events (64 [16.9%]) were the next most common. One hundred ninety-eight (52.2%) adverse events were characterized as less serious. However, 145 (38.3%) events were deemed serious, 28 (7.4%) life-threatening, and 8 (2.1%) fatal. In terms of preventability, 267 (70.4%) adverse events were found to be preventable or ameliorable, with less serious events more often considered preventable or ameliorable (146 [73.7%]) compared with more severe events (121 [66.9%]). In addition, resident care-related adverse events such as fall with injury, skin tear, and pressure ulcer were more commonly deemed preventable (173 of 197 [87.8%]) compared with adverse drug events (39 of 64 [60.9%]) or health care-acquired infections (49 of 108 [45.4%]). Conclusions and Relevance: Adverse events developed in nearly 4 of 10 of discharges from hospital back to LTC. Most were preventable or ameliorable. Standardized reporting of events and better coordination and information transfer across settings are potential ways to prevent adverse events in LTC residents.

Sex-Specific Differences in End-of-Life Burdensome Interventions and Antibiotic Therapy in Nursing Home Residents With Advanced Dementia.
Access if not affiliated with University of Alberta

N. M. Stall, H. D. Fischer, K. Fung, et al.
JAMA Netw Open 2019 Aug 2;2(8):e199557
Nursing home residents with advanced dementia have limited life expectancies yet are commonly subjected to burdensome interventions at the very end of life. Whether sex-specific differences in the receipt of these interventions exist and what levels of physical restraints and antibiotics are used in this terminal setting are unknown. Objective: To evaluate the population-based frequency, factors, and sex differences in burdensome interventions and antibiotic therapy among nursing home residents with advanced dementia. Design, Setting, and Participants: This population-based cohort study from Ontario, Canada, used linked administrative databases held at ICES, including the Continuing Care Resident Reporting System Long-Term Care database, which contains data from the Resident Assessment Instrument Minimum Data Set, version 2.0. Nursing home residents (n = 27243) with advanced dementia who died between June 1, 2010, and March 31, 2015, at 66 years or older were included in the analysis. Initial statistical analysis was completed in May 2017, and analytical revisions were conducted from November 2018 to January 2019. Exposure: Sex of the nursing home resident. Main Outcomes and Measures: Burdensome interventions (transitions of care, invasive procedures, and physical restraints) and antibiotic therapy in the last 30 days of life. Results: The final cohort included 27243 nursing home residents with advanced dementia (19363 [71.1%] women) who died between June 1, 2010, and March 31, 2015, at the median (interquartile range) age of 88 (83-92) years. In the last 30 days of life, burdensome interventions were common, especially among men: 5940 (21.8%) residents were hospitalized (3661 women [18.9%] vs 2279 men [28.9%]; P < .001), 2433 (8.9%) had an emergency department visit (1579 women [8.2%] vs 854 men [10.8%]; P < .001), and 3701 (13.6%) died in an acute care facility (2276 women [11.8%] vs 1425 men [18.1%]; P < .001). Invasive procedures were also common; 2673 residents (9.8%) were attended for life-threatening critical care (1672 women [8.6%] vs 1001 men [12.7%]; P < .001), and 210 (0.8%) received mechanical ventilation (113 women [0.6%] vs 97 men [1.2%]; P < .001). Among the 9844 residents (36.1%) who had a Resident Assessment Instrument Minimum Data Set, version 2.0, completed in the last 30 days of life, 2842 (28.9%) were physically restrained (2002 women [28.3%] vs 840 men [30.4%]; P = .005). More than one-third (9873 [36.2%]) of all residents received an antibiotic (6599 women [34.1%] vs 3264 men [41.4%]; P < .001). In multivariable models, men were more likely to have a transition of care (adjusted odds ratio, 1.41; 95% CI, 1.33-1.49; P < .001) and receive antibiotics (adjusted odds ratio, 1.33; 95% CI, 1.26-1.41; P < .001). Only 3309 residents (12.1%; 2382 women [12.3%] vs 927 men [11.8%]) saw a palliative care physician in the year before death, but those who did experienced greater than 50% lower odds of an end-of-life transition of care (adjusted odds ratio, 0.48; 95% CI, 0.43-0.54); P < .001) and greater than 25% lower odds of receiving antibiotics (adjusted odds ratio, 0.74; 95% CI, 0.68-0.81; P < .001). Conclusions and Relevance: In this study, many nursing home residents with advanced dementia, especially men, received burdensome interventions and antibiotics in their final days of life. These findings appear to emphasize the need for sex-specific analysis in dementia research as well as the expansion of palliative care and end-of-life antimicrobial stewardship in nursing homes.

 

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Events & Training Opportunities

Enhancing the mealtime experience for residents in retirement and long-term care

Thursday 7 November 09:00-15:30 Waterloo, ON
Presenter: Heather Keller
You may have heard about the CHOICE+ Program and the various resources created to date that are focused on improving mealtimes in long-term care. Over the past year, we have piloted CHOICE+ in three homes and have learned how this program can be implemented. We have developed a one-day training program to help more homes with making similar mealtime improvements and piloting this program.
Participants will receive a detailed manual outlining steps for making change and how to access and use CHOICE+ resources to help their team improve mealtimes.

Why Organizations, Researchers, and Patients Are Falling Prey to Predatory Journals

Thursday 10 October available in person or via live stream 11:30-12:30
Presenter: Kelly Cobey
This interactive talk will provide an overview of what predatory journals are and describe how they are having an impact on organizations, researchers, and patients. In doing so, the talk will touch on related topics, including academic incentives, research funding, and science policy. The impact of predatory journals on knowledge synthesis efforts and health literacy will be discussed, and recommendations will be made regarding safeguards that stakeholders can put in place to limit interaction with these journals and to help reduce waste in how biomedical research is shared and used.

Cochrane Standard Author Training workshop

26-28 November
University of Alberta, ECHA
In this workshop, you will learn basic skills, including:
– Developing a protocol
– Defining a research question
– Planning and conducting a systematic literature search
– Selecting studies and extracting data
– Critical appraisal
– Assessing bias
– Analysis and meta-analysis
– Assessing the certainty of evidence and interpreting your analysis
– Using Review Manager software

Quality Improvement Practicum

Available online
Begins 24 September
On a global scale, the challenges facing health and health care can seem daunting. But every day, people all over the world are making a difference​ on a local level. If you’ve identified an opportunity for ​​improvement ​— whether it is a process in your system, outcomes for your customers, or your own daily work — this online course will help you put your ideas into action.​​
During this 9-week online course, you will:
​​Explore the components of the Model for Improvement.
Build an improvement team with clearly defined roles.
Write an effective aim statement for a quality improvement (QI) project.
Establish a family of measures, including outcome, process, and balancing measures. Create a data collection plan.
Use tools to develop changes to test including Driver Diagrams, Process Mapping, and​ Cause and Effect Diagrams.
Use PDSAs (Plan-Do-Study-Act) to plan and run multiple tests.
Plot your data over time by drawing a run chart.
​Identify strategies to sustain and spread improvements

2019 Online KT Conference

28, 30 October & 1 November, 11:00-15:00 each day
Are you interested in learning innovative strategies for maximizing your knowledge translation (KT) research and development activities? Register today for the Center on KTDRR’s 2019 Online KT Conference: Innovative KT Strategies That Work!

Implementation science: If it’s not knowledge translation, and not change management, what is it?

Tuesday 3 September 8:30-09:00 (networking breakfast), 09:00-10:30 (keynote presentation)
Presenter: Carl May
Recent years have seen an enormous growth in interest in implementation science as a field. Implementation scientists, masters and doctoral programs in implementation science, and implementation research centres have proliferated. The rapidity of this change has been startling, and it has accelerated in the past five years. The important claim of implementation science is that the combination of relevant theory and rigorous research methods will lead to improvements in our capacity to engineer two kinds of improvement in health, healthcare practice, and healthcare systems:

The effective translation of high qualitive evidence into practice through the application of behaviour change techniques that are focused on individuals and populations.

The effective transformation of healthcare practices and systems through the application of practice implementation models that are focused on collectives and systems.

These involve very different ways of seeing the world. The first draws on something that Canada has always been very famous for—research on knowledge translation and mobilization—but is anchored in psychological theories of individual behaviour. The second draws on a wider range of theories and investigative techniques that are concerned with change, but are anchored in a long history of research on the dynamics of collective action, the diffusion of innovations, and the behaviour of complex social networks and groups.

In this talk, Dr. Carl May will do four things. First, Dr. May will explore the implications of these two approaches for implementation practice in the real world. Second, he will consider their implications for understanding the complicated and difficult tasks involved in engineering the successful implementation of innovations in the delivery and organization of health care. Third, he will reflect on experiences of implementation processes in Australia, the UK, and the US as examples of the interaction between science and real-world practices. Finally, he will offer a brief introduction to a simple model of implementation processes that incorporates both individual behaviours and collective action.

Igniting innovation and thinking through implementation with Normalization Process Theory (NPT)

Tuesday 3 September 11:00 AM–Wednesday 4 September 2019 06:00
Presenter: Carl May
The Institute of Health Economics is pleased to present a two-day workshop for policy leaders, healthcare providers, managers, and researchers involved in the planning and implementation of health innovation, with renowned speakers Dr. Carl May, Professor of Medical Sociology at the London School of Hygiene and Tropical Medicine, and Dr. Tracy Finch, Professor of Healthcare & Implementation Science at Northumbria University.

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Resources

Synthesis Review Toolkit

This toolkit was developed to guide individuals from various academic backgrounds through their journey of conducting a synthesis review.

Active Implementation Hub

The Active Implementation Hub is a free, online learning environment for use by any stakeholder — practitioners, educators, coaches, trainers, purveyors — involved in active implementation and scaling up of programs and innovations. The site goal is to increase the knowledge and improve the performance of persons engaged in actively implementing any program or practice.
While AI Modules and Lessons offer activities well-suited for many human service fields, the site currently focuses on active implementation and scaling up in the field of Education. Most e-learning content is appropriate for implementation teams, implementation specialists, administrators and technical assistance/professional development providers at any level in a system (e.g., district, region, state, national).

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News

Encouraging the Use of Research to Guide Practice and Policy

To Address Gaps in Care, Map the Process Together

New minister for seniors in Sask. sees much work ahead

Why are the intros to academic articles so boring?

Anxiety complicates life for dementia patients — and their caregivers

Scientific meetings damage the environment, and we should drastically curtail them

Fluoride won’t make you dumber, but the ‘debate’ about its safety might

How can academics keep up with the literature?

Patient and public involvement in research: What, why and how?

Sexism in the Academy Women’s narrowing path to tenure

New book: Getting the Most out of Your Doctorate: The Importance of Supervision, Networking and Becoming a Global Academic

Nursing home residents with advanced dementia often experience ‘burdensome interventions’ in final days of life: study

Nursing home residents with advanced dementia often face ‘distressing’ transfers, MDs find

Fourteen knowledge translation competencies and how to improve yours

Designing for dementia: Long-term memory care, from the ground up

Tête-à-tête with Tassi: Minister of Seniors talks about Canada’s first national dementia strategy

B.C. looks to keep people out of long-term care for longer

Life-changing messages for people with dementia

Health CEO calls out New Brunswick for long waitlists for
nursing home beds

Province of Quebec invests $15 million in HCA education to address worker shortages

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Opportunities

Advanced Evidence and Knowledge Analyst

Public Health Wales NHS Trust
Cardiff, UK
DEADLINE: 9 September
The Public Health Wales Observatory Evidence Service is looking for an Advanced Public Health Evidence & Knowledge Analyst to undertake evidence synthesis and take an active role in training, staff development and research relating to evidence synthesis.

The Public Health Wales Observatory provides public health intelligence and research evidence support to teams within Public Health Wales NHS Trust and works closely with Wales Health Boards, Local Authorities, Welsh Assembly Government and Public Health academia. The Observatory includes the Evidence Service and the Analytical Team and operates on a networked basis with offices across Wales.

If you have high level of evidence synthesis skill and experience and enthusiasm for embracing new technologies, we would welcome your application.

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