Sacral neuromodulation in nursing home residents: Predictors of success and complications in a national cohort of older adults.

AIMS: There is limited evidence to support the efficacy of sacral neuromodulation (SNM) for older adults with overactive bladder (OAB). This study aims to report outcomes following SNM among nursing home (NH) residents, a vulnerable population with high rates of frailty and comorbidity. METHODS: This is a retrospective cohort study of long-stay NH residents who underwent a trial of percutaneous nerve evaluation (PNE) or Stage 1 permanent lead placement (Stage 1) between 2014 and 2016. Residents were identified using the Minimum Data Set linked to Medicare claims. The primary outcome of this study was successful progression from trial to implant. Rates of 1-year device explant/revisions were also investigated. RESULTS: Trial of SNM was observed in 1089 residents (mean age: 77.9 years). PNE was performed in 66.9% of residents and 33.2% underwent Stage 1. Of Stage 1 procedures, 23.8% were performed with simultaneous device implant (single-stage). Overall, 53.1% of PNEs and 72.4% of Stage 1 progressed to device implant, which was associated with Stage 1 procedure versus PNE (adjusted relative risk [aRR]: 1.34; 95% confidence interval [95% CI]: 1.21-1.49) and female versus male sex (aRR: 1.26; 95% CI: 1.09-1.46). One-year explant/revision was observed in 9.3% of residents (6.3% for PNE, 10.5% for Stage 1, 20.3% single-stage). Single stage procedure versus PNE was significantly associated with device explant/revision (aRR: 3.4; 95% CI: 1.9-6.2). CONCLUSIONS: In this large cohort of NH residents, outcomes following SNM were similar to previous reports of younger healthier cohorts. Surgeons managing older patients with OAB should use caution when selecting patients for single stage SNM procedures.

Potential for remote vital sign monitoring to improve hospital patient sleep: A feasibility study.

BACKGROUND: Even low-acuity patients suffer from disrupted sleep in the hospital in part due to routine overnight vital sign (VS) checks. When invasive monitoring is not needed, vital sign monitoring devices (VSMDs) similar to consumer-grade health monitors may play a role in promoting sleep, which can aid healing and recovery. METHODS: We provided one VSMD to neuroscience ward patients during their hospital stays and used surveys to assess patient and nurse attitudes toward the device and the impact of the device on patient comfort. We also compared VSMD-streamed vS data to nurse-recorded vS data in the chart to evaluate the consistency of data streaming and data concordance between the device and nurse-collected vital sign values. FINDINGS: 21 patients and 15 nurses enrolled. Overall, patients and nurses responded positively to the device and patients preferred wearing the device to receiving manual vital checks overnight. The most common device-related cause of sleep disruption per patients was device weight (29%). Device vS were concordant with nurse vS on average but there was significant variance in agreement between nurse and device values. INTERPRETATION: Patients and nurses feel positively about the use of VSMDs and their use in the hospital. The device we tested may be limited in its sleep promotion by its weight and patient comfort assessment. Further research is needed to assess the precision of the device in measuring vital signs when used in a clinical setting. Future studies should compare VSMD models and assess their impacts on patient sleep in the absence of manual vS checks overnight. FUNDING: Funding provided by the Sara & Evan Williams Foundation Endowed Neurohospitalist Chair at UCSF.

Effect of two counseling interventions on self-reported alcohol consumption, alcohol biomarker phosphatidylethanol (PEth), and viral suppression among persons living with HIV (PWH) with unhealthy alcohol use in Uganda: A randomized controlled trial.

PURPOSE: To test the efficacy of two interventions to reduce alcohol use and increase viral suppression compared to a control in persons with HIV (PWH). METHODS: In a three-arm (1:1:1) randomized controlled trial (N = 269), we compared in-person counselling (45-70 minutes, two sessions over three months) with interim monthly booster phone calls (live call arm) or twice-weekly automated booster sessions (technology arm) to a brief advice control arm. We enrolled PWH self-reporting unhealthy alcohol use (Alcohol Use Disorders Identification Test - Consumption, prior three months, women ≥3, men ≥4). Primary outcomes were number of self-reported drinking days (NDD) in the prior 21 and biomarker phosphatidylethanol (PEth) at six and nine months and viral suppression (<40 copies/mL) at nine months; we adjusted for sex and baseline outcomes. RESULTS: At baseline, mean 21-day NDDs were 9.4 (95 % CI: 9.1-9.8), mean PEth was 407.8 ng/mL (95 % CI: 340.7-474.8), and 89.2 % were virally suppressed. At follow-up, there were significant reductions in mean NDDs for the live call versus control arm (3.5, 95 % CI:2.1-4.9, p < 0.001) and for the technology versus control arm (3.6, 95 % CI: 2.2-5.1, p < 0.001). The mean PEth differences compared to the control arm were not significant, i.e. 36.4 ng/mL (95 % CI: -117.5 to 190.3, p = 0.643) for the live call and -30.9 ng/mL (95 % CI: -194.8 to 132.9, p = 0.711) for the technology arm. Nine-month viral suppression compared to the control was similar in the live call and in the technology arm. CONCLUSION: Intervention effects were found on self-reported NDD but not PEth or viral suppression, suggesting no treatment effect. (NCT #03928418).

Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: A multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients.

BACKGROUND: Few hospitals have built surveillance for diagnostic errors into usual care or used comparative quantitative and qualitative data to understand their diagnostic processes and implement interventions designed to reduce these errors. OBJECTIVES: To build surveillance for diagnostic errors into usual care, benchmark diagnostic performance across sites, pilot test interventions, and evaluate the program's impact on diagnostic error rates. METHODS AND ANALYSIS: Achieving diagnostic excellence through prevention and teamwork (ADEPT) is a multicenter, real-world quality and safety program utilizing interrupted time-series techniques to evaluate outcomes. Study subjects will be a randomly sampled population of medical patients hospitalized at 16 US hospitals who died, were transferred to intensive care, or had a rapid response during the hospitalization. Surveillance for diagnostic errors will occur on 10 events per month per site using a previously established two-person adjudication process. Concurrent reviews of patients who had a qualifying event in the previous week will allow for surveys of clinicians to better understand contributors to diagnostic error, or conversely, examples of diagnostic excellence, which cannot be gleaned from medical record review alone. With guidance from national experts in quality and safety, sites will report and benchmark diagnostic error rates, share lessons regarding underlying causes, and design, implement, and pilot test interventions using both Safety I and Safety II approaches aimed at patients, providers, and health systems. Safety II approaches will focus on cases where diagnostic error did not occur, applying theories of how people and systems are able to succeed under varying conditions. The primary outcome will be the number of diagnostic errors per patient, using segmented multivariable regression to evaluate change in y-intercept and change in slope after initiation of the program. ETHICS AND DISSEMINATION: The study has been approved by the University of California, San Francisco Institutional Review Board (IRB), which is serving as the single IRB. Intervention toolkits and study findings will be disseminated through partners including Vizient, The Joint Commission, and Press-Ganey, and through national meetings, scientific journals, and publications aimed at the general public.

Beta-Blocker Use in U.S. Nursing Home Residents After Myocardial Infarction: A National Study.

OBJECTIVES: To evaluate how often beta-blockers were started after acute myocardial infarction (AMI) in nursing home (NH) residents who previously did not use these drugs and to evaluate which factors were associated with post-AMI use of beta-blockers. DESIGN: Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. SETTING: U.S. NHs. PARTICIPANTS: National cohort of 15,720 residents aged 65 and older who were hospitalized for AMI between May 2007 and March 2010, had not taken beta-blockers for at least 4 months before their AMI, and survived 14 days or longer after NH readmission. MEASUREMENTS: The outcome was beta-blocker initiation within 30 days of NH readmission. RESULTS: Fifty-seven percent (n = 8,953) of residents initiated a beta-blocker after AMI. After covariate adjustment, use of beta-blockers was less in older residents (ranging from odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-1.00 for aged 75-84 to OR = 0.65, 95% CI = 0.54-0.79 for ≥95 vs 65-74) and less in residents with higher levels of functional impairment (dependent or totally dependent vs independent to limited assistance: OR = 0.84, 95% CI = 0.75-0.94) and medication use (≥15 vs ≤10 medications: OR = 0.89, 95% CI = 0.80-0.99). A wide variety of resident and NH characteristics were not associated with beta-blocker use, including sex, cognitive function, comorbidity burden, and NH ownership. CONCLUSION: Almost half of older NH residents in the United States do not initiate a beta-blocker after AMI. The absence of observed factors that strongly predict beta-blocker use may indicate a lack of consensus on how to manage older NH residents, suggesting the need to develop and disseminate thoughtful practice standards.

Secondary Prevention Medication Use After Myocardial Infarction in U.S. Nursing Home Residents.

BACKGROUND/OBJECTIVES: Secondary prevention medications are recommended for older adults after acute myocardial infarction (AMI), but little is known about whether nursing home (NH) residents receive these medications. The objective was to evaluate new use of secondary prevention medications after AMI in NH residents who were previously nonusers and to evaluate what factors were associated with use. DESIGN: Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. SETTING: U.S. NHs. PARTICIPANTS: National cohort of 11,192 NH residents aged 65 and older who were hospitalized for an AMI between May 2007 and March 2010, had no beta-blocker or statin use for 4 months or longer before the hospitalization, and survived 14 days or more after NH readmission. MEASUREMENTS: The outcome was the number of secondary prevention medications initiated within 30 days of NH readmission. RESULTS: Thirty-seven percent of residents had no secondary prevention medications initiated after AMI, 41% had 1 initiated, and 22% had 2 initiated. After covariate adjustment, fewer secondary prevention medications were used in older residents (proportional odds ratio (POR) = 0.48, 95% confidence interval (CI)  = 0.40-0.57 for ≥95 vs 65-74); women (POR = 0.88, 95% CI = 0.80-0.96);and those with a do-not-resuscitate (DNR) order (POR = 0.90, 95% CI = 0.83-0.98), functional impairment (dependent or totally dependent vs independent to limited assistance, POR = 0.77, 95% CI = 0.69-0.86), and cognitive impairment (moderate to severe vs no impairment, POR = 0.79, 95% CI = 0.70-0.89). CONCLUSION: More than one-third of older NH residents in the United States do not have any secondary prevention medications initiated after AMI, with fewer medications initiated in older residents; women; and those with, DNR orders, poor physical function, and cognitive impairment. A lack of evidence about the safety and effectiveness of secondary preventions medications in the NH population and unmeasured person-centered goals of care are plausible explanations for these findings.

Increase in Disability Prevalence Before Hip Fracture.

OBJECTIVES: To establish the prevalence and correlates of disability during the 2 years before hip fracture. DESIGN: Data from participants who experienced hip fracture in the Health and Retirement Study (HRS) with hip fracture identified using linked Medicare claims. Each participant was interviewed at varying time points in the 2 years before hip fracture. Disability was defined as self-report of the need for assistance in any activity of daily living (walking across the room, eating, bathing, dressing, using the toilet, transferring). Based on the timing between interview and hip fracture, prevalence of disability was calculated in the cohort as a whole over the 2 years before hip fracture and in subgroups defined according to demographic and clinical characteristics. SETTING: The HRS is a nationally representative longitudinal study (1992-2010). PARTICIPANTS: HRS participants aged ≥65 with hip fracture (mean age at fracture 84, 77% female). RESULTS: The adjusted prevalence of disability was 20% (95% confidence interval (CI) = 14-25%) 2 years before hip fracture, with little change until approximately 10 months before fracture, when it started to rise, reaching 44% (95% CI = 33-55%) in the month before hip fracture. The prevalence of disability was highest in the last month before fracture for persons aged 85 and older (53%) and for those with dementia (60%). CONCLUSION: Care models for hip fracture need to consider not only the acute medical and surgical needs, but also the high level of need for supportive care and caregiver assistance that chronically disabled individuals require.

Patterns of multimorbidity in elderly veterans.

OBJECTIVES: To determine patterns of co-occurring diseases in older adults and the extent to which these patterns vary between the young-old and the old-old. DESIGN: Observational study. SETTING: Department of Veterans Affairs. PARTICIPANTS: Veterans aged 65 years and older (1.9 million male, mean age 76 ± 7; 39,000 female, mean age 77 ± 8) with two or more visits to Department of Veterans Affairs (VA) or Medicare settings in 2007 and 2008. MEASUREMENTS: The presence of 23 common conditions was assessed using hospital discharge diagnoses and outpatient encounter diagnoses from the VA and Medicare. RESULTS: The mean number of chronic conditions (out of 23 possible) was 5.5 ± 2.6 for men and 5.1 ± 2.6 for women. The prevalence of most conditions increased with advancing age, although diabetes mellitus and hyperlipidemia were 11% to 13% less prevalent in men and women aged 85 and older than in those aged 65 to 74 (P < .001 for each). In men, the most common three-way combination of conditions was hypertension, hyperlipidemia, and coronary heart disease, which together were present in 37% of men. For women, the most common combination was hypertension, hyperlipidemia, and arthritis, which co-occurred in 25% of women. Reflecting their high population prevalence, hypertension and hyperlipidemia were both present in 9 of the 15 most common three-way disease combinations in men and in 11 of the 15 most common combinations in women. The prevalence of many disease combinations varied substantially between young-old and old-old adults. CONCLUSIONS: Specific combinations of diseases are highly prevalent in older adults and inform the development of guidelines that account for the simultaneous presence of multiple chronic conditions.

Preliminary evidence for subdimensions of geriatric frailty: the MacArthur study of successful aging.

OBJECTIVES: To identify frailty subdimensions. DESIGN: Longitudinal cohort (MacArthur Study). SETTING: Three U.S. urban centers. PARTICIPANTS: One thousand one hundred eighteen high-functioning subjects aged 70 to 79 in 1988. MEASUREMENTS: Participants with three or more of five Cardiovascular Health Study (CHS) frailty criteria (weight loss, weak grip, exhaustion, slow gait, and low physical activity) in 1991 were classified as having the CHS frailty phenotype. To identify frailty subdimensions, factor analysis was conducted using the CHS variables and an expanded set including the CHS variables, cognitive impairment, interleukin-6 (IL-6), C-reactive protein (CRP), subjective weakness, and anorexia. Participants with four or more of 10 criteria were classified as having an expanded frailty phenotype. Predictive validity of each identified frailty subdimension was assessed using regression models for 4-year disability and 9-year mortality. RESULTS: Two subdimensions of the CHS phenotype and four subdimensions of the expanded frailty phenotype were identified. Cognitive function was consistently part of a subdimension including slower gait, weaker grip, and lower physical activity. The CHS subdimension of slower gait, weaker grip, and lower physical activity predicted disability (adjusted odds ratio (AOR)=1.7, 95% confidence interval (CI)=1.3-2.2) and mortality (AOR=1.5, 95% CI=1.3-1.8). Subdimensions of the expanded model with predictive validity were higher IL-6 and CRP (AOR=1.2 for mortality); slower gait, weaker grip, lower physical activity, and lower cognitive function (AOR=1.8 for disability; AOR=1.5 for mortality), and anorexia and weight loss (AOR=1.2 for disability). CONCLUSION: This study provides preliminary empirical support for subdimensions of geriatric frailty, suggesting that pathways to frailty differ and that subdimension-adapted care might enhance care of frail seniors.