Effectiveness of a Smart Urinary Continence Care Assessment System for Nursing Home Residents: A Quasi-Experimental, Sequential Quantitative-Qualitative Methods Trial.

PURPOSE: The purpose of this study was to compare the effect of use of an electronic urinary continence assessment system versus usual care on construction of care plans, resource use, and continence care for nursing home (NH) residents. DESIGN: Convergent mixed-methods study comprising a prospective, parallel arm-controlled phase, and concurrent qualitative component. SUBJECTS AND SETTING: The study setting was Alberta, a province in Western Canada. Residents requiring a continence assessment or reassessment in an NH with 2 units assigned to intervention (I) and 2 units to usual care (UC). One hundred one residents (I: n = 49; UC: n = 52) participated; 89 (I: n = 43; UC: n = 46) completed the study. The mean age of the UC group was 88.5 (SD = 6.9) years, whereas the mean age of the intervention group was 85.6 (SD = 7.5) years. METHODS: Quantitative data on assessment, resource use, resident quality of life, and continence care outcomes were collected at weeks 0, 2, and 8; plan adherence was assessed at week 16. Qualitative data were collected via interviews. RESULTS: Analysis revealed a significant change in the proportion of residents achieving a reduction in 24-hour pad absorbency (50.6% vs 39.1%, P = .034) at week 8. There were significant differences in between-group changes (total absorbency of pads used in 24 hours and total cost of night pads used). Both groups reported improved health-related quality of life. Analysis of qualitative data revealed 3 themes: resource use; quality of continence care; and system utility and limitations. CONCLUSIONS: A technological solution offering a standardized system of continence assessment provided benefit in terms of quality of care for residents and use of continence containment products; utility was validated by staff.

Predictors of improvement in urinary incontinence in the postacute setting: A Canadian cohort study.

PURPOSE: To determine factors associated with improvement in urinary incontinence (UI) for long-stay postacute, complex continuing care (CCC) patients. DESIGN: A retrospective cohort investigation of patients in a CCC setting using data obtained from the Canadian Institute for Health Information's Continuing Care Reporting System collected with interRAI Minimum Data Set 2.0. SETTING AND PARTICIPANTS: Individuals aged 18 years and older, were admitted to CCC hospitals in Ontario, Canada, between 2010 and 2018. METHODS: Multivariable logistic regression was used to determine the independent effects of predictors on UI improvement, for patients who were somewhat or completely incontinent on admission and therefore had the potential for improvement. RESULTS: The study cohort consisted of 18 584 patients, 74% (13 779) of which were somewhat or completely incontinent upon admission. Among those patients with potential for improvement, receiving bladder training, starting a new medication 90 days prior (odds ratio, OR: 1.54 [95% confidence interval, CI: 1.36-1.75]), and triggering the interRAI Urinary Incontinence Clinical Assessment Protocol to facilitate improvement (OR: 1.36 [95% CI: 1.08-1.71]) or to prevent decline (OR: 1.32 [95% CI: 1.13-1.53]) were the strongest predictors of improvement. Conversely, being totally dependent on others for transfer (OR: 0.62 [95% CI: 0.42-0.92]), is rarely or never understood (OR: 0.65 [95% CI: 0.50-0.85]), having a major comorbidity count of ≥3 (OR: 0.72 [95% CI: 0.59-0.88]), Parkinson's disease, OR: 0.77 (95% CI: 0.62-0.95), Alzheimer/other dementia, OR: 0.83 (95% CI: 0.74-0.93), and respiratory infections, OR: 0.57 (95% CI: 0.39-0.85) independently predicted less likelihood of improvement in UI. CONCLUSIONS AND IMPLICATIONS: Findings of this study suggest that improving physical function, including bed mobility, and providing bladder retraining have strong positive impacts on improvement in UI for postacute care patients. Evidence generated from this study provides useful care planning information for care providers in identifying patients and targeting the care that may lead to better success with the management of UI.

What are the chances of improvement or cure from overactive bladder? A pooled responder analysis of efficacy and treatment emergent adverse events following treatment with fesoterodine.

AIM: This study describes patients with different degrees and combinations of symptom resolution in response to fesoterodine exposure to aid physicians in counselling patients with overactive bladder (OAB) on the likelihood of treatment success. METHODS: Data came from 12-week fixed-dose studies of fesoterodine. The proportions of patients experiencing symptom resolution and change in patient-reported outcome measures (PROM) at 4, 8, and 12 weeks were calculated. Treatment-emergent adverse events (TEAE) were reported according to response in urinary urgency episodes (UUE). The relationship between PROM and response was examined. RESULTS: Out of 6689 patients, 81.6% female, urgency urinary incontinence (UUI) episodes/24 h were more responsive to fesoterodine than UUE; with roughly 50% of patients reporting a 50% reduction and fewer than 10% reporting absence of UUE at 12 weeks compared to approximately 40%-50% reporting absence of UUI. TEAE was numerically lower in patients with greater response. There was a statistically significant relationship between improvement in urinary urgency and associated change in OAB-q symptom bother scores, r = 0.54, p < 0.001. At Week 4, 64.0%-76.7% of patients who had achieved a significant change in Patient Perception of Bladder Condition (PPBC) had a 50% reduction in UUI. At Week 12 this proportion was between 80% and 87.9%, with those being exposed to fesoterodine treatment reporting response in PPBC at numerically higher rates. CONCLUSION: These data provide clinicians with information from which they may usefully communicate the likelihood of symptom resolution in response to pharmacotherapy for OAB and answer a key clinical question posed by many care providers. Roughly ⅓ of fesoterodine treated patients reported a 50% reduction urgency and ¾ reported 50% resolution of incontinence at 12 weeks. Total resolution of all symptoms was seldom achieved.

Assessment of patients with lower urinary tract symptoms where an undiagnosed neurological disease is suspected: A report from an International Continence Society consensus working group.

AIM: Lower urinary tract symptoms (LUTS) are a common urological referral, which sometimes can have a neurological basis in a patient with no formally diagnosed neurological disease ("occult neurology"). Early identification and specialist input is needed to avoid bad LUTS outcomes, and to initiate suitable neurological management. METHODS: The International Continence Society established a neurological working group to consider: Which neurological conditions may include LUTS as an early feature? What diagnostic evaluations should be undertaken in the LUTS clinic? A shortlist of conditions was drawn up by expert consensus and discussed at the annual congress of the International Neurourology Society. A multidisciplinary working group then generated recommendations for identifying clinical features and management. RESULTS: The relevant conditions are multiple sclerosis, multiple system atrophy, normal pressure hydrocephalus, early dementia, Parkinsonian syndromes (including early Parkinson's Disease and Multiple System Atrophy) and spinal cord disorders (including spina bifida occulta with tethered cord, and spinal stenosis). In LUTS clinics, the need is to identify additional atypical features; new onset severe LUTS (excluding infection), unusual aspects (eg, enuresis without chronic retention) or "suspicious" symptoms (eg, numbness, weakness, speech disturbance, gait disturbance, memory loss/cognitive impairment, and autonomic symptoms). Where occult neurology is suspected, healthcare professionals need to undertake early appropriate referral; central nervous system imaging booked from LUTS clinic is not recommended. CONCLUSIONS: Occult neurology is an uncommon underlying cause of LUTS, but it is essential to intervene promptly if suspected, and to establish suitable management pathways.

Correction to: Association between nocturia and frailty among elderly males in a veterans administration population.

In the original publication of the article, the author's name Jeffrey P. Weiss was misspelled as "Jeffry P. Weiss".

Association between nocturia and frailty among elderly males in a veterans administration population.

BACKGROUND: The relationship between frailty and nocturnal voiding is poorly understood. AIM: To characterize the association between frailty, as defined by a frailty index (FI) based upon the Canadian Study of Health and Aging (CSHA) criteria, and nocturia, defined by measures of nocturnal urine production. METHODS: Real-world retrospective analysis of voiding diaries from elderly males with lower urinary tract symptoms (LUTS) at an outpatient urology clinic. Males ≥ 65 years with ≥ 2 nocturnal voids were included. A modified FI was calculated from the LUTS database, which captured 39 variables from the original CSHA FI. Patients were divided into 3 groups by modified FI: low (≤ 0.077) (n = 59), intermediate (> 0.077 and < 0.179) (n = 58), and high (≥ 0.179) (n = 41). Diary parameters were compared using the Kruskal-Wallis test and pairwise comparisons with the Wilcoxon rank-sum test and Bonferroni adjustment. RESULTS: The high frailty group was characterized by higher nocturnal urine volume (NUV), maximum voided volume (MVV), nocturnal maximum voided volume (NMVV), and nocturnal urine production (NUP). The presence of comorbid diabetes mellitus did not explain this effect. CONCLUSION: Elderly males seeking treatment for LUTS with a high frailty burden are disproportionately affected by excess nocturnal urine production. Future research on the mechanistic relationship between urine production and functional impairment is warranted.

Examining the Impact of Knowledge Translation Interventions on Uptake of Evidence-Based Practices by Care Aides in Continuing Care.

BACKGROUND: Dissemination of evidence-based practices has been a long-standing challenge for healthcare providers and policy makers. Research has increasingly focused on effective knowledge translation (KT) in healthcare settings. AIMS: This study examined the effectiveness of two KT interventions, informal walkabouts and documentation information sessions, in supporting care aide adoption of new evidence-based practices in continuing care. METHODS: The Sustaining Transfers through Affordable Research Translation (START) study examined sustainability of a new practice, the sit-to-stand activity completed with residents in 23 continuing care facilities in Alberta, Canada. At each facility, two informal walkabouts and two documentation information sessions were conducted with care aides during the first 4 months. To assess their effect, uptake of the sit-to-stand activity was compared 4 days prior to and 4 days after each intervention, as well as the entire first and fourth months of the study were compared. Data were analyzed using mixed linear regression models created to estimate the changes in uptake. RESULTS: Data were collected from 227 residents. After controlling for age, sex, dementia, and mobility, a 5.3% (p = .09) increase in uptake of the mobility activity was observed during the day shift and 6.1% (p = .007) increase in uptake of the mobility activity during the evening shift. Site size had a significant effect on the outcome with medium-sized facilities showing a 12.6% (SE = .07) increase over small sites and a 18.2% (SE = .05) increase over large sites. These results suggest that repeated KT interventions and sufficient time are key variables in the successful implementation of new practices. LINKING EVIDENCE TO ACTION: Consideration of time, repetition, and facility-specific variables such as size may generate simple, cost-effective KT interventions in healthcare settings.

Development and initial psychometric properties of the 'ICIQ-Cog': a new assessment tool to measure the disease-related impact and care effort associated with incontinence in cognitively impaired adults.

OBJECTIVES: To develop a new assessment tool, the ICIQ-Cog, to measure the disease-related impact of incontinence in cognitively impaired adults and the effort associated with the care of this population, and to present the initial psychometric properties of this tool and outline the possible clinical implications. PARTICIPANTS AND METHODS: The ICIQ-Cog consists of two scales: a 12-item scale measuring disease-specific bother (ICIQ-Cog-P) and a four-item scale assessing efforts associated with care of people with incontinence and cognitive impairment (ICIQ-Cog-C). Data on 60 nursing home residents with incontinence and cognitive impairment were obtained in a test-retest research design. The psychometric properties of the ICIQ-Cog were examined using a combination of classic and item response theory methods. RESULTS: Factor analyses resulted in a three-factor solution for the ICIQ-Cog-P, with interrelated factors. Rasch analysis showed a good model fit when collapsing response categories. The ICIQ-Cog-C fitted to one dimension. The ICIQ-Cog tool provided reliable measures in terms of internal consistency (0.69-0.82) and retest reliability (0.71-0.83). The preliminary results on external validity showed that the ICIQ-Cog assessed disease-specific aspects linked to the group of cognitively impaired people with incontinence. CONCLUSION: The ICIQ-Cog tool has appropriate psychometric and clinometric properties and is therefore useful for making decisions about treatment in cognitively impaired adults with incontinence.

Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study.

BACKGROUND: Frailty is a state of vulnerability to diverse stressors. We assessed the impact of frailty on outcomes after discharge in older surgical patients. METHODS: We prospectively followed patients 65 years of age or older who underwent emergency abdominal surgery at either of 2 tertiary care centres and who needed assistance with fewer than 3 activities of daily living. Preadmission frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale as "well" (score 1 or 2), "vulnerable" (score 3 or 4) or "frail" (score 5 or 6). We assessed composite end points of 30-day and 6-month all-cause readmission or death by multivariable logistic regression. RESULTS: Of 308 patients (median age 75 [range 65-94] yr, median Clinical Frailty Score 3 [range 1-6]), 168 (54.5%) were classified as vulnerable and 68 (22.1%) as frail. Ten (4.2%) of those classified as vulnerable or frail received a geriatric consultation. At 30 days after discharge, the proportions of patients who were readmitted or had died were greater among vulnerable patients (n = 27 [16.1%]; adjusted odds ratio [OR] 4.60, 95% confidence interval [CI] 1.29-16.45) and frail patients (n = 12 [17.6%]; adjusted OR 4.51, 95% CI 1.13-17.94) than among patients who were well (n = 3 [4.2%]). By 6 months, the degree of frailty independently and dose-dependently predicted readmission or death: 56 (33.3%) of the vulnerable patients (adjusted OR 2.15, 95% CI 1.01-4.55) and 37 (54.4%) of the frail patients (adjusted OR 3.27, 95% CI 1.32-8.12) were readmitted or had died, compared with 11 (15.3%) of the patients who were well. INTERPRETATION: Vulnerability and frailty were prevalent in older patients undergoing surgery and unlikely to trigger specialized geriatric assessment, yet remained independently associated with greater risk of readmission for as long as 6 months after discharge. Therefore, the degree of frailty has important prognostic value for readmission. TRIAL REGISTRATION FOR PRIMARY STUDY: ClinicalTrials.gov, no. NCT02233153.

Can we define and characterize the aging lower urinary tract?-ICI-RS 2015.

The prevalence of lower urinary tract (LUT) symptoms increases with age but the etiology is unknown. This article aims to identify research directions that clarify the basis of this association. The initial question is whether biological age is the variable of interest or a time-dependent accumulation of factors that impact on LUT function at rates that differ between individuals. In particular, the accumulation of conditions or agents due to inflammatory states or tissue ischemia is important. Much of the above has been concerned with changes to bladder function and morphology. However, the outflow tract function is also affected, in particular changes to the function of external sphincter skeletal muscle and associated sacral motor nerve control. Nocturia is a cardinal symptom of LUT dysfunction and is more prevalent with aging. Urine production is determined by diurnal changes to the production of certain hormones as well as arterial blood pressure and such diurnal rhythms are blunted in subjects with nocturia, but the causal links remain to be elucidated. Changes to the central nervous control of LUT function with age are also increasingly recognized, whether in mid-brain/brainstem regions that directly affect LUT function or in higher centers that determine psycho-social and emotional factors impinging on the LUT. In particular, the linkage between increasing white matter hyperintensities and LUT dysfunction during aging is recognized but not understood. Overall, a more rational approach is being developed to link LUT dysfunction with factors that accumulate with age, however, the precise causal pathways remain to be characterized. Neurourol. Urodynam. 36:854-858, 2017. © 2017 Wiley Periodicals, Inc.

Persistence and adherence with mirabegron vs antimuscarinics in overactive bladder: Retrospective analysis of a UK General Practice prescription database.

INTRODUCTION AND OBJECTIVES: Persistence with antimuscarinic (AM) drugs prescribed for overactive bladder (OAB) is poor. This study aimed to compare persistence and adherence with the beta-3-adrenoceptor agonist mirabegron (MIR) vs AMs over 12 months. PATIENTS AND METHODS: This retrospective cohort analysis included patients aged ≥18 years who were prescribed MIR, or any AM. A 12-month look-back was used to assess inclusion eligibility. The primary end-point was persistence, defined as time to first discontinuation of index drug, during 1 year follow-up. The secondary end-point was adherence, estimated by medication possession ratio (MPR). RESULTS: Inclusion criteria were met by 6189 patients. Those prescribed AMs were mostly treatment-naïve (range 72.9%-95.3%) vs 54.4% of MIR patients. There was greater persistence with MIR vs AM. The median number of days on therapy with MIR was 101, vs 27-56 for AMs. Patients receiving AMs were significantly more likely to discontinue than those receiving MIR (hazard ratio [HR] range 1.24-2.05, P < .01 for each AM vs MIR. In treatment-naïve patients, HRs ranged from 1.25 (solifenacin, P = .012) to 2.07 (oxybutynin IR, P < .001). In treatment-experienced patients, they ranged from 1.10 (fesoterodine, P = NS) to 2.12 (oxybutynin IR, P < .001). Adherence was greater with MIR (mean MPR 48.4%) than with AMs (range 27.6%-40.4%, P < .001). Treatment-experienced patients were significantly less likely to discontinue treatment (HR 0.87, P = .006). DISCUSSION AND CONCLUSION: MIR was associated with a significantly longer time to discontinuation, greater persistence and better adherence than AMs. However, there was a steep decline in persistence with all drugs after 1 month. This is unlikely to be wholly explained by anticholinergic adverse events, as it was also seen with MIR. The lower proportion of MIR patients who were treatment-naive reflects current prescribing guidelines whereby MIR is prescribed after an initial generic AM trial. The study was limited by the small number of MIR patients. Study identifier: ISN 178-MA-3059.

Optimizing senior's surgical care - Elder-friendly Approaches to the Surgical Environment (EASE) study: rationale and objectives.

BACKGROUND: It is estimated that seniors (≥65 years old) account for >50% of acute inpatient hospital days and are presenting for surgical evaluation of acute illness in increasing numbers. Unfortunately, conventional acute care models rarely take into account needs of the elderly population. The failure to consider these special needs have resulted in poor outcomes, longer lengths of hospital stay and have likely increased the need for institutional care. Acute Care for the Elderly models on medical wards have demonstrated decreased cost, length of hospital stay, readmissions and improved cognition, function and patient/staff satisfaction. We hypothesize that specific Elder-friendly Approaches to the Surgical Environment (EASE) interventions will similarly improve health outcomes in a cost-effective manner. METHODS/DESIGN: Prospective, before-after study with a concurrent control group. Four cohorts of 140 consecutively-screened older patients (≥65 years old) will be enrolled (560 patients in total). The EASE interventions involves co-locating all older surgical patients on a single unit, involving an interdisciplinary care team (including a geriatric specialist) in the development of individual care plans, implementing evidence-informed elder-friendly practices, use of a reconditioning program, and optimizing discharge planning. Subjects will be followed via chart review for their hospital stay, and will then complete in-person or telephone interviews at 6 weeks and 6 months after discharge. Measured outcomes include clinical (postoperative major in-hospital complication or death [primary composite outcome]; death or readmission within 30-days of initial discharge; length of hospital stay), humanistic (quality of life; functional, cognitive, and nutritional status) and economic (health care resource utilization and costs) endpoints. Within-site mean change scores will be computed for the composite primary outcome and the overall covariate-adjusted between-site pre-post difference will be the dependent variable analyzed using generalized linear mixed model procedures including adjustment for clustering. DISCUSSION: Our findings will generate new knowledge on outcomes from acute surgical care in older patients and validate a novel elder-friendly surgical model including assessment of both clinical and economic benefits. If effective, we expect the EASE initiatives to be generalizable to other surgical centres. TRIAL REGISTRATION: Clinicaltrials.govidentifier: NCT02233153.

Functional properties and connective tissue content of pediatric human detrusor muscle.

The functional properties of human pediatric detrusor smooth muscle are poorly described, in contrast to those of adult tissue. Characterization is necessary for more informed management options of bladder dysfunction in children. We therefore compared the histological, contractile, intracellular Ca2+ concentration responses and biomechanical properties of detrusor biopsy samples from pediatric (3-48 mo) and adults (40-60 yr) patients who had functionally normal bladders and were undergoing open surgery. The smooth muscle fraction of biopsies was isolated to measure proportions of smooth muscle and connective tissue (van Gieson stain); in muscle strips, isometric tension to contractile agonists or electrical field stimulation and their passive biomechanical properties; in isolated myocytes, intracellular Ca2+ concentration responses to agonists. Pediatric detrusor tissue compared with adult tissue showed several differences: a smaller smooth muscle-to-connective tissue ratio, similar contractures to carbachol or α,ß-methylene ATP when corrected for smooth muscle content, and similar intracellular Ca2+ transients to carbachol, α,ß-methylene ATP, raised K+ concentration or caffeine, but smaller nerve-mediated contractions and greater passive stiffness with slower stress relaxation. In particular, there were significant atropine-resistant nerve-mediated contractions in pediatric samples. Detrusor smooth muscle from functionally normal pediatric human bladders is less contractile than that from adult bladders and exhibits greater passive stiffness. Reduced bladder contractile function is not due to reduced smooth muscle contractility but to greater connective tissue deposition and to functional denervation. Significant atropine resistance in pediatric detrusor, unlike in adult tissue, demonstrates a different profile of functional neurotransmitter activation. These data have implications for the management of pediatric bladder function by therapeutic approaches.

A plain language summary of the likelihood of symptom relief for patients taking fesoterodine for overactive bladder.

WHAT IS THIS SUMMARY ABOUT?: This is a summary of a study originally published in Neurourology and Urodynamics. Overactive bladder is a medical condition that causes an urgent need to urinate, which can cause accidental urination. Fesoterodine is a medication used to treat overactive bladder. Because we don't know how likely it is that an individual patient will achieve a level of improvement in their overactive bladder symptoms, researchers analyzed results of 6 studies of patients with overactive bladder who were treated with fesoterodine. WHAT WERE THE RESULTS?: Although complete resolution of all symptoms was rare with fesoterodine treatment, a resolution of accidental urination was more common, which is the most important treatment goal for many patients. After taking fesoterodine, episodes of accidental urination were more likely to be reduced or completely absent than episodes of an urgent need to urinate. WHAT DO THE RESULTS OF THE STUDY MEAN?: These results can help patients with overactive bladder understand their own chances of treatment success with fesoterodine and can help doctors support their patients on what to expect regarding their specific symptoms and concerns. ▪Toviaz (fesoterodine) is approved to treat the condition that is discussed in this summary. Approval varies from country to country; please check with your local health provider for more details. ▪This summary reports the combined results of 6 studies. The results of individual studies may vary from the combined study results presented here. Individuals should make treatment decisions based on all available evidence. ClinicalTrials.gov NCT number: NCT01302054, NCT01302067, NCT00444925, NCT00611026, NCT00220363, and NCT00138723.

Changes in Urinary Continence After Admission to a Complex Care Setting: A Multistate Transition Model.

OBJECTIVES: To examine changes in urinary continence for post-acute, Complex Continuing Care hospital patients from time of admission to short-term follow-up, either in hospital or after discharge to long-term care or home with services. DESIGN: Retrospective cohort study of patients in Complex Continuing Care hospitals using clinical data collected with interRAI Minimum Data Set 2.0 and interRAI Resident Assessment Instrument Home Care. SETTING AND PARTICIPANTS: Adults aged 18 years and older, admitted to Complex Continuing Care hospitals in Ontario, Canada, between 2009 and 2015 (n = 78,913). METHODS: A multistate transition model was used to characterize the association between patient characteristics measured at admission and changes in urinary continence state transitions (continent, sometimes continent, and incontinent) between admission and follow-up. RESULTS: The cohort included 27,896 patients. At admission, 9583 (34.3%) patients belonged to the continent state, 6441 (23.09%) patients belonged to the sometimes incontinent state, and the remaining 11,872 (42.6%) patients belonged to the incontinent state. For patients who were continent at admission, the majority (62.7%) remained continent at follow-up. However, nearly a quarter (23.9%) transitioned to the sometimes continent state, and an additional 13.4% became incontinent at follow-up. Several factors were associated with continence state transitions, including cognitive impairment, rehabilitation potential, stroke, Parkinson's disease, Alzheimer's disease and related dementias, and hip fracture. CONCLUSIONS AND IMPLICATIONS: This study suggests that urinary incontinence is a prevalent problem for Complex Continuing Care hospital patients and multiple factors are associated with continence state transitions. Standardized assessment of urinary incontinence is helpful in this setting to identify patients in need of further assessment and patient-centered intervention and as a quality improvement metric to examine changes in continence from admission to discharge.

Mobility of Vulnerable Elders (MOVE): study protocol to evaluate the implementation and outcomes of a mobility intervention in long-term care facilities.

BACKGROUND: Almost 90% of residents living in long-term care facilities have limited mobility which is associated with a loss of ability in activities of daily living, falls, increased risk of serious medical problems such as pressure ulcers, incontinence and a significant decline in health-related quality of life. For health workers caring for residents it may also increase the risk of injury. The effectiveness of rehabilitation to facilitate mobility has been studied with dedicated research assistants or extensively trained staff caregivers; however, few investigators have examined the effectiveness of techniques to encourage mobility by usual caregivers in long-term care facilities. METHODS/DESIGN: This longitudinal, quasi-experimental study is designed to demonstrate the effect of the sit-to-stand activity carried out by residents in the context of daily care with health care aides. In three intervention facilities health care aides will prompt residents to repeat the sit-to-stand action on two separate occasions during each day and each evening shift as part of daily care routines. In three control facilities residents will receive usual care. Intervention and control facilities are matched on the ownership model (public, private for-profit, voluntary not-for-profit) and facility size. The dose of the mobility intervention is assessed through the use of daily documentation flowsheets in the health record. Resident outcome measures include: 1) the 30-second sit-to-stand test; 2) the Functional Independence Measure; 3) the Health Utilities Index Mark 2 and 3; and, 4) the Quality of Life - Alzheimer's Disease. DISCUSSION: There are several compelling reasons for this study: the widespread prevalence of limited mobility in this population; the rapid decline in mobility after admission to a long-term care facility; the importance of mobility to quality of life; the increased time (and therefore cost) required to care for residents with limited mobility; and, the increased risk of injury for health workers caring for residents who are unable to stand. The importance of these issues is magnified when considering the increasing number of people living in long-term care facilities and an aging population. TRIAL REGISTRATION: This clinical trial is registered with ClinicalTrials.gov (trial registration number: NCT01474616).

Patient reported outcomes in an elder-friendly surgical environment: Prospective, controlled before-after study.

INTRODUCTION: The Acute Care for the Elderly (ACE) model has demonstrated clinical benefit, but there is little evidence regarding quality of life after discharge. The Elder-friendly Approaches to the Surgical Environment (EASE) study was conducted to assess implementation of an ACE unit on an acute surgical service. Improved clinical and economic outcomes have been demonstrated, but post-discharge patient reported outcomes have not yet been reported. METHODS: Prospective, concurrently controlled, before-after study at two tertiary care hospitals in Alberta, Canada. The SF-12, EQ-5D, Canadian Malnutrition Screening Tool (CMST) and patient satisfaction were collected from elderly (≥ 65 years old) patients, 6 weeks and 6 months after discharge from an acute care surgical service. A difference-in-difference (DID) method was used to analyze between-site effects. RESULTS: At six weeks, patient satisfaction was high at 68%-86%, with significant improvement Pre-to Post-EASE at the control site (p < 0.001), but not the intervention site (p = 0.06). For the intervention site, within-site adjusted pre-post effects were nonsignificant for all patient reported outcomes [EQ-Index Score ß coefficient (SE): 0.042 (0.022); EQ-Visual Analog Scale: 0.10 (2.14); SF-12 Physical Component Score: -0.57 (0.84); SF-12 Mental Component Score: 1.17 (0.84); CMST Score: -0.39 (0.34)]. DID analyses were also non significant for all outcomes except for SF-12 Mental Component Score (p < 0.001). CONCLUSION: The clinically and economically beneficial EASE interventions do not appear to compromise quality of life, risk for malnutrition, or patient satisfaction in the post-discharge period. Further research with larger sample size is needed with comparisons to pre-intervention and the early post-discharge period.

Prioritizing research: Patients, carers, and clinicians working together to identify and prioritize important clinical uncertainties in urinary incontinence.

AIMS: Research often neglects important gaps in existing evidence. Throughout healthcare, clinicians and patients face avoidable "clinical uncertainties" daily, making decisions about treatments without reliable evidence about their effects. This partnership of patients and clinicians aimed to identify and prioritize "clinical uncertainties" relating to treatment of urinary incontinence (UI). METHODS: UK clinician and patient organizations whose remit includes UI were invited to participate. Participating organizations consulted memberships to identify "uncertainties" affecting treatment decisions. "Uncertainties" were also identified in published research recommendations. Prioritization involved two phases: shortlisting of "uncertainties" by organizations; patient-clinician prioritization using established consensus methods. Prioritized "uncertainties" were verified by checking any available relevant up-to-date published systematic reviews. RESULTS: Thirty organizations were invited; 8 patient and 13 clinician organizations participated. Consultation generated 417 perceived "uncertainties," research recommendations 131. Refining, excluding and combining produced a list of 226. Prioritization shortlisted 29 "uncertainties," then a "top ten" (5 submitted by clinicians, 4 by patients, 1 from research recommendations). CONCLUSIONS: The partnership successfully developed and tested a systematic and transparent methodology for patient-clinician consultation and consensus. Through consensus, unanswered research questions of importance to patients and clinicians were identified and prioritized. The final list reflects the heterogeneity of populations, treatments and evidence needs associated with UI. Some prioritized "uncertainties" relate to treatments that are widely used yet whose effects are not thoroughly understood, some to access to care, some to precise surgical questions. Research needs to address the uncertainties range from systematic reviewing to primary research.

Effectiveness of reminders to sustain practice change among direct care providers in residential care facilities: a cluster randomized controlled trial.

BACKGROUND: The study purpose was to compare the effectiveness of monthly or quarterly peer reminder knowledge translation interventions, with monthly or quarterly paper-based reminders, to sustain a mobility innovation, the sit-to-stand activity. METHOD: A cluster RCT using a stratified 2 × 2 factorial design was conducted in 24 Canadian residential care facilities with 416 residents and 54 peer reminder care aides. The 1-year intervention included two intensities of reminders (high: socially based peer reminders delivered by volunteer care aides to other care aides; low: paper-based reminders posted in residents' rooms), at two frequencies (monthly; every 3 months). Intervention fidelity was assessed using questionnaires and observations. Monthly sustainability rate of the sit-to-stand activity was calculated as the percentage of opportunities that residents successfully completed the activity in 30 days. Residents' sustainability rates were analyzed using a linear mixed model that mirrored the clustered repeated-measures factorial trial design. The model included a random intercept to account for clustering within sites. An unstructured covariance structure characterized the interdependence of repeated measures over time. RESULTS: Twenty-four sites were randomized. One site was excluded because of falsifying data, leaving 23 sites and 349 residents for intention-to-treat analysis. Paper reminders were implemented with high fidelity across all arms (91.5% per protocol), while the peer reminders were implemented with moderate fidelity in the monthly group (81.0% per protocol) and poor fidelity in the quarterly group (51.7% per protocol). At month 1, mean sustainability ranged from 40.7 to 47.2 per 100 opportunities, across the four intervention arms (p = 0.43). Mean rate of sustainability in the high intensity, high frequency group diverged after randomization, yielding statistically significant differences among the groups at 4 months which persisted for the remainder of the trial. After 12 months, the mean sustainability in the high intensity, high frequency group was approximately twice that of the other three groups combined (64.1 versus 37.8 per 100 opportunities, p < 0.001). CONCLUSIONS: A monthly peer reminder intervention was more effective than a quarterly peer reminder intervention, a monthly paper-based reminder intervention, and a quarterly paper-based reminder intervention, in supporting care aides to sustain a mobility innovation in residential care facilities over 1 year. TRIAL REGISTRATION: ClinicalTrials.gov , NCT01746459. Registered 11 December 2012: https://clinicaltrials.gov/ct2/show/NCT01746459 .