Protein energy wasting and long-term outcomes in nondialysis dependent chronic kidney disease.

BACKGROUND: Nutritional status and protein energy wasting (PEW) is prevalent in patients with nondialysis-dependent chronic kidney disease (CKD). The relationship between PEW and long-term development of clinically important outcomes remains to be examined. OBJECTIVES: To investigate the relationships between PEW, as measured by Subjective Global Assessment (SGA 1-7), and progression to important clinical outcomes: mortality and/or kidney failure. DESIGN: Prospective cohort design. PARTICIPANTS: One hundred and thirty-nine participants were well-nourished and 37 moderately malnourished patients with CKD 3-5. MEASUREMENTS: The outcomes were 2, 5, and 10-year progression to kidney failure (dialysis or transplant) or mortality, kidney failure alone, and mortality alone. SGA was determined by a registered renal dietitian. Food frequency questionnaires were used to assess dietary intake. Clinical and laboratory baseline characteristics were collected. Multivariable regression models and Cox models were created to examine the relationship between SGA and outcomes. RESULTS: PEW was associated with the combined outcome of kidney failure or mortality at 2 (p = 0.003), 5 (p = 0.004), but not at 10 (p = 0.73) years. This relationship was primarily driven by the relationship between PEW and kidney failure. In Cox models, the relationship between PEW and kidney failure remained after adjusting for Kidney Failure Risk Equation scores. The multivariable modeling revealed that PEW remained a statistically significant predictor of the combined outcome and ESKD after adjustment for age, estimated glomerular filtration rate (eGFR), sex, albumin-to-creatinine ratio, diabetes, albumin, and protein intake. CONCLUSIONS: PEW, determined by the SGA 1-7, is an important prognostic tool. Further research looking at clinically important outcomes are needed to implement nutritional interventions for nondialysis-dependent CKD patients.

"I Hope That the People Caring for Me Know About Me": Exploring Person-Centred Care and the Quality of Dementia Care.

Background: Person-centred care is at the core of high-quality dementia care but people living with dementia are often excluded from quality improvement efforts. We sought to explore person-centred care and quality of care from the perspectives of persons living with dementia in the community and their care partners. Methods: We used a qualitative descriptive approach with in-person, semi-structured interviews with 17 participants (9 persons living with dementia and 8 care partners) from Ontario, Canada. Results: Participants report that person-centred care is essential to the quality of dementia care. Three themes were identified that describe connections between person-centred care and quality of care: 1) "I hope that the people looking after me know about me", 2) "I just like to understand [what's happening] as we go down the road", and 3) "But the doctor doesn't even know all the resources that are available." Participants perceived that quality indicators over-emphasized technical/medical aspects of care and do not entirely capture quality of care. Conclusions: Persons living with dementia and their care partners provide important insights into person-centredness and quality of care. Their perspectives on "quality" may differ from clinicians and researchers. Research is needed to better integrate their perspectives in quality improvement and person-centred care.

Push and Pull Factors Surrounding Older Adults' Relocation to Supportive Housing: A Scoping Review.

Supportive housing, including retirement homes and assisted living, is increasingly touted as a suitable living option for Canadian older adults. This scoping review describes the nature and content of studies that explore underlying factors that motivate older adults to relocate to supportive housing. We conducted a search of PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science, and PsycINFO, which identified 34 articles for review. Articles reviewed employed a variety of methods and guiding theoretical frameworks, of which the push and pull framework appeared to be most common. This review suggests that health and functional deficits are important reasons for relocation to supportive housing for older adults. Further longitudinal data are required to more comprehensively describe medical and social determinants for relocation and its consequences, in order to better describe this growing population and better align policies with the needs of older adults contemplating or undergoing relocation.

Delivery of Virtual Care in Oncology: Province-Wide Interprofessional Consensus Statements Using a Modified Delphi Process.

Virtual cancer care (i.e., teleoncology) was rapidly adopted during the COVID-19 pandemic to meet the needs of patients with cancer. However, there is a paucity of guidance for clinicians regarding virtual cancer care. We sought to develop consensus-based statements to guide the optimal provision of virtual care for clinicians caring for patients with cancer, using a modified Delphi consensus process with a 29-member panel consisting of an interprofessional group of clinicians caring for patients with cancer and patient representatives. The consensus process consisted of two rounds and one synchronous final consensus meeting. At the end of the modified Delphi process, 62 of 62 statements achieved consensus. Fifty-seven statements reached consensus in the first round of the process. Concerns regarding the ability to convey difficult news virtually and maintaining similar standards as in-person care without disproportionate strain on clinicians and patients were addressed in the consensus process. We achieved interprofessional consensus on virtual cancer care practices. Further research examining the impact of virtual cancer care on person-centred and clinical outcomes are needed to inform practices during the COVID-19 pandemic and beyond.

Towards Consensus on Essential Components of Physical Examination in Primary Care-based Memory Clinics.

BACKGROUND: Primary care-based memory clinics were established to meet the needs of persons with memory concerns. We aimed to identify: 1) physical examination maneuvers required to assess persons with possible dementia in specialist-supported primary care-based memory clinics, and 2) the best-suited clinicians to perform these maneuvers in this setting. METHODS: We distributed in-person and online surveys of clinicians in a network of 67 primary care-based memory clinics in Ontario, Canada. RESULTS: 90 surveys were completed for an overall response rate of 66.7%. Assessments of vital signs, gait, and for features of Parkinsonism were identified as essential by most respondents. There was little consensus on which clinician should be responsible for specific physical examination maneuvers. CONCLUSIONS: While we identified specific physical examination maneuvers deemed by providers to be both necessary and feasible to perform in the context of primary care-based memory clinics, further research is needed to clarify interprofessional roles related to the examination.

Quality of Dementia Care in the Community: Identifying Key Quality Assurance Components.

BACKGROUND: Primary care-based memory clinics (PCMCs) have been established in several jurisdictions to improve the care for persons with Alzheimer's disease and related dementias. We sought to identify key quality indicators (QIs), quality improvement mechanisms, and potential barriers and facilitators to the establishment of a quality assurance framework for PCMCs. METHODS: We employed a Delphi approach to obtain consensus from PCMC clinicians and specialist physicians on QIs and quality improvement mechanisms. Thirty-eight candidate QIs and 19 potential quality improvement mechanisms were presented to participants in two rounds of electronic Delphi surveys. Written comments were collected and descriptively analyzed. RESULTS: The response rate for the first and second rounds were 21.3% (n = 179) and 12.8% (n = 88), respectively. The majority of respondents were physicians. Fourteen QIs remained after the consensus process. Ten quality improvement mechanisms were selected with those characterized by specialist integration, such as case discussions and mentorships, being ranked highly. Written comments revealed three major themes related to potential barriers and facilitators to quality assurance: 1) perceived importance, 2) collaboration and role clarity, and 3) implementation process. CONCLUSION: We successfully utilized a consultative process among primary and specialty providers to identify core QIs and quality improvement mechanisms for PCMCs. Identified quality improvement mechanisms highlight desire for multi-modal education. System integration and closer integration between PCMCs and specialists were emphasized as essential for the provision of high-quality dementia care in community settings.