Implementing Caregiver Support Programs in a Regional Stroke System.

Background and Purpose- Family caregivers play a central role in the recovery of people with stroke. They need support to optimize the care they provide and their own health and well-being. Despite support from the literature and best practice recommendations, healthcare systems are not formally adopting caregiver programs. This study aimed to describe system-level facilitators and barriers to caregiver support program implementation in a regional stroke system. Methods- Using a qualitative descriptive study design, focus groups were conducted with regional rehabilitation specialists, education coordinators, community and long-term care specialists, and regional/district program directors. Semi-structured interviews were conducted with regional medical directors, health professionals providing stroke care in acute care, rehabilitation and community settings, regional health executives, and primary care leaders. Data were analyzed using inductive thematic analysis. Results- Four focus groups (n=43) and 29 interviews were conducted. We identified 4 themes related to caregiver program implementation: (1) establishing the need for caregiver education and support in an integrated healthcare system; (2) incorporating caregiver programs into the system of care across the care continuum; (3) uncertainty regarding ownership and responsibility for implementation; and (4) addressing regional variations related to access, availability, and culture. Conclusions- This study provides a comprehensive understanding of organization and system-level considerations for implementing caregiver programs in a regional stroke system. Program implementation requires evidence to establish the need for caregiver programs, practical strategies, and establishing ownership to incorporate programs into existing healthcare systems, and consideration of regional variations across healthcare systems. Ultimately, adopting programs to support caregivers will improve recovery in people with stroke and caregiver well-being.

Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis.

Importance: Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise. Objective: To assess the potential effectiveness of interventions for preventing falls. Data Sources: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned. Study Selection: Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older. Data Extraction and Synthesis: Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted. Main Outcomes and Measures: Injurious falls and fall-related hospitalizations. Results: A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], -0.67 [95% CI, -1.10 to -0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, -1.79 [95% CI, -2.63 to -0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, -1.19 [95% CI, -2.04 to -0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, -2.08 [95% CI, -3.56 to -0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]). Conclusions and Relevance: Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences.

Impact of vitamin D supplementation on health-care use in a 25-hydroxyvitamin D-tested population in France: a population-based descriptive cohort study.

OBJECTIVE: Chronic vitamin D deficiency has been associated in some patients with diffuse musculoskeletal pain. These unspecific symptoms may partly explain why vitamin D deficiency is often diagnosed late. Our aim was to analyse health-care claims after vitamin D supplementation in patients likely to have vitamin D deficiency. DESIGN: Ambulatory health-care claims were compared before and after a vitamin D supplementation prescribed following a 25-hydroxyvitamin D assay. SETTING: Health Insurance Fund (FHIF) database of the Rhône-Alpes area, France. SUBJECTS: Among patients reimbursed for a 25-hydroxyvitamin D assay between 1 December 2008 and 31 January 2009, those supplemented with vitamin D after the assay were matched on the date of assay to patients who did not receive vitamin D. RESULTS: Among the 3023 patients who had a 25-hydroxyvitamin D assay, 935 were consequently supplemented and matched to 935 patients not supplemented. Their median age was 50·0 and 49·5 years, respectively. Patients supplemented decreased their muscle relaxant consumption whereas no change was observed in the reference group, the difference between the two groups was significant (P=0·03). Second and third Pain Relief Ladder prescriptions decreased in both groups but not significantly differently between groups (P=0·58). There was a decrease in prescriptions of biological examination in both groups with no significant difference. CONCLUSIONS: Besides a decrease in muscle relaxant prescriptions in the supplemented group, it was difficult to assess the impact of vitamin D supplementation in patients likely to have vitamin D deficiency. Prospective cohort studies and randomized trials are needed to assess the efficiency of screening and supplementing vitamin D deficiency.

Secondary health conditions and spinal cord injury: an uphill battle in the journey of care.

PURPOSE: To understand the journey of care in the prevention and management of secondary health conditions (SHCs) following spinal cord injury (SCI). METHOD: This was a case study design with 'Ontario' as the case. The Network Episode Model was used as the conceptual framework. Data sources included in depth interviews with persons with SCI, care providers, and policy and decision makers. Document analysis was also conducted on relevant materials and policies. Key informants were selected by purposeful sampling as well as snowball sampling to provide maximum variation. Data analysis was an iterative process and involved descriptive and interpretive analyses. A coding structure was developed based on the conceptual framework which allowed for free nodes when emerging ideas or themes were identified. RESULTS: Twenty-eight individuals were interviewed (14 persons with SCI and 14 persons representing care providers, community advocacy organization representatives, system service delivery administrators and policy-makers). A major over-arching domain that emerged from the data was the concept of 'fighting'. Eleven themes were identified: at the micro-individual level: (i) social isolation and system abandonment, (ii) funding and equitable care, (iii) bounded freedom and self-management; at the meso care provider level: (iv) gender and caregiving strain, (v) help versus disempowerment, (vi) holistic care-thinking outside the box, (vii) poor communication and coordination of care; and at the macro health system level: (viii) fight for access and availability, (ix) models of care tensions, (x) private versus public tensions and (xi) rigid rules and policies. CONCLUSIONS: Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. If we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level. IMPLICATIONS FOR REHABILITATION: • Secondary health conditions are problematic for individuals with a spinal cord injury (SCI). • This study aimed to understand the journey of care in the prevention and management of secondary health conditions (SHCs) following SCI. • Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. • All stakeholders involved recognized the disparities in access to care and resources that exist within the system. We recommend that if we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.

Fracture prevalence and treatment with bone-sparing agents: are there urban-rural differences? A population based study in Ontario, Canada.

OBJECTIVE: To estimate the prevalence of self-reported osteoporotic fractures and use of bone-sparing agents, and to examine if region of residence is associated with fracture or treatment prevalence. METHODS: A census of persons aged > or = 55 years residing in 2 regions of Ontario, Canada (East York, a region within Toronto, and Oxford County), was completed between 1995 and 1998. Region was coded by record linkage of residential postal codes to 1996 Canadian Census data into 4 groups: East York (urban core), and Oxford County subdivided into: urban core, small urban, and rural. Respondents were excluded if they resided outside the regions of interest or were missing fracture data (5%). RESULTS: A total of 26,839 persons (15,541 women) were studied. Nearly 3 times as many women as men reported having had an osteoporotic fracture (14% vs 5%), with 31% and 8%, respectively, taking bone-sparing agents. Controlling for age, a diagnosis of osteoporosis, number of osteoporotic fractures, and height loss, women residing in East York were more likely (OR 1.2, 95% CI 1.0-1.4) to be taking a bone-sparing agent other than estrogen, but less likely to be taking estrogen (OR 0.8, 95% CI 0.7-0.9) compared to those living in rural areas. No regional differences were observed in fracture prevalence, treatment among those with an osteoporotic fracture, or use of a bone-sparing agent among men. CONCLUSION: Further research into regional differences in osteoporosis screening, treatment, and fractures is warranted. This should examine the appropriateness of possible differences, and separate physician practice patterns from patient characteristics, such as willingness to begin treatment with bone-sparing agents.

The development of Partners for Health's integrated community pathway for postmyocardial infarction patients.

Partners for Health convened an interdisciplinary team to evaluate the quality of care received by cardiac patients. The team detailed the suboptimal postacute care of patients with ischemic heart disease. To solve the quality problems, a cross-sectoral team, using an approach that is in accordance with the American Heart Association's Scientific Statement on Pathways, systematically developed and implemented an integrated community pathway for myocardial infarction patients. The paper contributes to the literature on pathways by presenting the lessons learned from the authors' first-hand experience. The paper concludes with recommendations based on those lessons.

Correlates of forearm bone mineral density in young Norwegian women: the Nord-Trøndelag Health Study.

Maximizing attainment of optimal peak bone mineral density (BMD) is a potential osteoporosis prevention strategy. The main objective of this study was to identify correlates of forearm BMD in young adult women. Population-based data derived from standardized questionnaires administered to healthy women aged 19-35 years in Nord-Trøndelag, Norway (n = 963), were collected in 1995-1997. Forearm BMD was assessed by single x-ray absorptiometry. Multiple linear and logistic regression analyses were used to determine correlates of BMD (g/cm(2)) and lowest quintile of BMD, respectively, at the ultradistal and distal sites. The mean age and weight of the cohort were 29.7 years (standard deviation 4.7) and 68.6 kg (standard deviation 12.5), respectively. Age and weight were positively associated with BMD at both forearm sites. When data were controlled for age and weight, later age at menarche and lack of milk consumption were associated with lower BMD values. In both linear models and logistic models, none of the factors vitamin D intake, physical activity, smoking, alcohol consumption, amenorrhea, oral contraceptive use, number of pregnancies, history of breastfeeding, and family history of osteoporosis were found to be significantly associated with BMD. Prior studies have suggested that calcium supplementation in children is useful for optimizing peak BMD. Further studies exploring the relation between lifestyle factors and BMD are warranted to search for ways to maximize attainment of peak BMD.