Improving hip fractures outcomes for COPD patients.

UNLABELLED: Hip fractures in the elderly have high rates of mortality and perioperative complications. Both men and COPD patients have worse mortality and complications but this may be due to more co-morbid disease. We assessed mortality and complications in a large cohort (n = 12,646) of men undergoing hip fracture surgery within the Veteran's Health Affairs (VHA) to define the association of COPD to these outcomes after adjusting for other key factors. We looked for opportunities to improve outcomes for COPD patients. METHODS: Using the VA Surgical Quality Improvement Program (VASQIP), and administrative databases, we determined COPD status, types of co-morbid conditions and surgical factors, and compared these to outcomes of surgical complications, 30-day and one-year mortality for patients who underwent hip fracture repair during 1998 to 2005. RESULTS: COPD was noted in 47% of the hip fracture patients studied. In 3,261 (26%) cases, the COPD was "severe: (indicated by functional disability, previous hospitalization for exacerbation, chronic drug treatment or record of FEV(1) <75% predicted), and in 2,736 (21%) cases it was considered "mild" (any previous outpatient visit or hospitalization with a coded diagnosis of COPD). Severe COPD patients had one year mortality of 40.2% compared to 31.0% in mild COPD and 28.8% in non-COPD subjects. Current smoking, use of general anesthesia and delays to surgery were significant modifiable risk factors identified in adjusted models. Osteoporosis was known pre-fracture in only 3% of subjects. CONCLUSIONS: COPD was very common in male veterans with hip fractures and was associated with increased risk of death and complications. Increased use of regional anesthesia and urgent scheduling of hip fracture surgery may improve outcomes for patients with COPD. Osteoporosis was rarely identified preoperatively. Improving diagnosis and treatment of osteoporosis in COPD patients could reduce the incidence of hip fractures.

Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients.

BACKGROUND: A lower proportion of patients with chronic heart failure receive palliative care compared to patients with advanced cancer. OBJECTIVE: We examined the relative need for palliative care in the two conditions by comparing symptom burden, psychological well-being, and spiritual well-being in heart failure and cancer patients. DESIGN: This was a cross-sectional study. PARTICIPANTS: Sixty outpatients with symptomatic heart failure and 30 outpatients with advanced lung or pancreatic cancer. MEASUREMENTS: Symptom burden (Memorial Symptom Assessment Scale-Short Form), depression symptoms (Geriatric Depression Scale-Short Form), and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being scale). MAIN RESULTS: Overall, the heart failure patients and the cancer patients had similar numbers of physical symptoms (9.1 vs. 8.6, p = 0.79), depression scores (3.9 vs. 3.2, p = 0.53), and spiritual well-being (35.9 vs. 39.0, p = 0.31) after adjustment for age, gender, marital status, education, and income. Symptom burden, depression symptoms, and spiritual well-being were also similar among heart failure patients with ejection fraction < or =30, ejection fraction >30, and cancer patients. Heart failure patients with worse heart failure-related health status had a greater number of physical symptoms (13.2 vs. 8.6, p = 0.03), higher depression scores (6.7 vs. 3.2, p = 0.001), and lower spiritual well-being (29.0 vs. 38.9, p < 0.01) than patients with advanced cancer. CONCLUSIONS: Patients with symptomatic heart failure and advanced cancer have similar needs for palliative care as assessed by symptom burden, depression, and spiritual well-being. This implies that heart failure patients, particularly those with more severe heart failure, need the option of palliative care just as cancer patients do.

Associations among nurse and certified nursing assistant hours per resident per day and adherence to guidelines for treating nursing home-acquired pneumonia.

BACKGROUND: Nursing home (NH)-acquired pneumonia (NHAP) causes excessive mortality, hospitalization, and functional decline, partly because many NH residents do not receive appropriate care. Care structures like nurse/resident staffing ratios can impede or abet quality care. This study examines the relationship between nurse/resident staffing ratios, turnover, and adherence to evidence-based guidelines for treating NHAP. METHODS: A prospective, chart-review study was conducted among residents of 16 NHs in three states with > or = 2 signs and symptoms of NHAP during the 2004--2005 influenza season. NH medical records were reviewed concurrently for functional status, comorbidity, NHAP severity, and guideline adherence. Ratio of licensed nurse and Certified Nursing Assistant (CNA) hours per resident per day (hrpd) and ratio of newly hired nursing staff/year to current nursing staff were provided by Directors of Nursing. Associations among guideline adherence, nurse and CNA hrpd, and turnover were assessed using multiple regression to adjust for case mix, facility characteristics, and clustering of residents in facilities. RESULTS: Mid (1.7-2.0) and high (> 2.0) CNA hrpd were significantly associated with better pneumococcal and influenza vaccination rates. More than 1.2 licensed nurse hrpd was significantly associated with appropriate hospitalization (odds ratio [OR] 12.4; 95% confidence interval [CI], 3.5-43.8) and guideline-recommended antibiotics (OR 3.8; 95% CI, 1.7-8.7). A > 70% turnover was inversely related to timely physician notification (OR 0.4; 95% CI, 0.2-0.7) and appropriate hospitalization (OR 0.09; 95% CI, 0.05-0.26). CONCLUSIONS: NHAP treatment guideline adherence is associated with nurse and CNA hrpd and stability. An NH's ability to implement evidence-based care may depend on adequate staffing ratios and stability.

"Meet Me Where I Am": Removing Barriers to End-of-Life Care for Homeless Veterans and Veterans Without Stable Housing.

OBJECTIVE:: To describe the barriers and facilitators of end-of-life (EOL) care for Veterans without stable housing (VWSH) as perceived by Veterans at 1 VA medical center and EOL care staff. DESIGN:: Qualitative descriptive study. Secondary applied content analysis of data from interviews and focus groups in our parent study. SETTING/PARTICIPANTS:: VA Puget Sound Health Care System and VWSH. RESULTS:: The core emergent theme in the words of Veterans and health-care workers was "meet me where I am," a statement of what many Veterans want most from their health care. Barriers and facilitators often reflected the presence or absence of important factors such as relationship and trust building, care coordination and flexibility, key individuals and services, and assistance in navigating change. CONCLUSIONS:: These findings suggest that to improve health care for VWSH, interventions must be multifaceted, including a suite of support services, flexibility and creative problem-solving, and adaptations in communication approaches. The authors offer specific recommendations for improving EOL care for VWSH based on these findings.

Addressing the Challenges of Palliative Care for Homeless Veterans.

BACKGROUND: Veterans who nearing the end of life (EOL) in unstable housing are not adequately served by current palliative care or homeless programs. METHODS: Multidisciplinary focus groups, interviews with community and Veterans Affairs (VA) leaders and with 29 homeless veterans were conducted in five cities. A forum of national palliative and homelessness care leaders (n=5) and representatives from each focus group (n=10), then convened. The forum used Nominal Group Process to suggest improvements in EOL care for veterans without homes. Modified Delphi Process was used to consolidate and prioritize recommendations during two subsequent tele-video conferences. Qualitative content analysis drew on meeting transcripts and field notes. RESULTS: The Forum developed 12 recommendations to address the following barriers: (1) Declining health often makes independent living or plans to abstain impossible, but housing programs usually require functional independence and sobriety. (2) Managing symptoms within the homelessness context is challenging. (3) Discontinuities within and between systems restrict care. (4) VA regulations challenge collaboration with community providers. (5) Veterans with unstable housing who are at EOL and those who care for them must compete nationally for prioritization of their care. CONCLUSION: Care of veterans at EOL without homes may be substantially improved through policy changes to facilitate access to appropriate housing and care; better dissemination of existing policy; cross-discipline and cross-system education; facilitated communication among VA, community, homeless and EOL providers; and pilot testing of VA group homes or palliative care facilities that employ harm reduction strategies.

Suboptimal pharmacotherapy in a tribal nursing home.

OBJECTIVE: Suboptimal medication use among nursing home (NH) residents is common. NH residents tend to be older, suffer from multiple conditions, and take numerous medications, increasing their risk of serious complications. This article examines pharmacotherapy in a rural, tribally owned NH. DESIGN: Medical records were reviewed and case studies were conducted by a team composed of a medical anthropologist, psychiatrist, and geriatrician. SETTING: A rural, American Indian-owned NH in the US northern plains. PARTICIPANTS: 40 American Indian and 5 EuroAmerican NH residents. MEASUREMENTS: Minimum Data Set assessments, admission records, care plans, social histories, prescription lists, and behavioral consultation reports. RESULTS: Potential underuse affected almost 75% of residents; undertreatment of depressive and psychotic/agitated symptoms was especially common. Potential inappropriate use, especially of analgesics, psychotropics, and antihistamines, affected 30% of residents. A smaller, but still substantial, number of residents (21%) experienced potential overuse, much of which involved anticonvulsants, antibiotics, cardiovascular, and psychotropic agents. The prescription of 10 or more medications was significantly associated with potential drug interactions, as well as underuse, inappropriate medication use, and overuse. CONCLUSIONS: Psychotropic medications were the most potentially problematic medication category, and were strongly implicated in potential underuse, inappropriate use, and overuse. Fewer medications; the discontinuation of drugs known to be potentially problematic for NH residents; modification of psychotropic medication regimens; use of cognitive-enhancing medications where appropriate; implementation of an electronic medical record system; and greater use of nonpharmacological behavioral interventions may have substantially improved residents' treatment regimens.

Assessing the appropriateness of pain medication prescribing practices in nursing homes.

OBJECTIVES: To test a tool for screening the quality of nursing home (NH) pain medication prescribing. DESIGN: Validity and reliability of measurement tool developed for a pre/postintervention with untreated comparison group. SETTING: Six treatment NHs and six comparison NHs in rural and urban Colorado. PARTICIPANTS: NH staff, physicians, and repeated 20% random sample of each home's residents (N = 2,031). INTERVENTION: Nurse and physician education; NH internal pain team to champion better pain management using a pain vital sign, consultations, and rounds. MEASUREMENTS: An expert panel reviewed the Pain Medication Appropriateness Scale (PMAS) for content validity. Research assistants interviewed NH residents, assessed them for pain using standardized instruments, and reviewed their medical records for prescriptions and use of pain and adjuvant medication. Construct validity was assessed by comparing the PMAS of residents in pain with the PMAS of those not in pain and comparing scores in homes in which the intervention was more effective with those in which it was less effective, using the Fisher exact and Student t tests. Interrater and test-retest reliability were measured. RESULTS: The mean total PMAS was 64% of optimal. Fewer than half of residents with predictably recurrent pain were prescribed scheduled pain medication; 23% received at least one high-risk medication. PMAS scores were better for residents not in pain (68% vs 60%, P = .004) and in homes where nurses' knowledge of pain assessment and management improved or stayed the same during the intervention (69% vs 61%, P = .03). CONCLUSION: The PMAS is useful for assessing pain medication prescribing in NHs and elucidates why so many residents have poorly controlled pain.

A multifaceted intervention to implement guidelines improved treatment of nursing home-acquired pneumonia in a state veterans home.

OBJECTIVES: To assess the feasibility of a multifaceted strategy to translate evidence-based guidelines for treating nursing home-acquired pneumonia (NHAP) into practice using a small intervention trial. DESIGN: Pre-posttest with untreated control group. SETTING: Two Colorado State Veterans Homes (SVHs) during two influenza seasons. PARTICIPANTS: Eighty-six residents with two or more signs of lower respiratory tract infection. INTERVENTION: Multifaceted, including a formative phase to modify the intervention, institutional-level change emphasizing immunization, and availability of appropriate antibiotics; interactive educational sessions for nurses; and academic detailing. MEASUREMENTS: Subjects' SVH medical records were reviewed for guideline compliance retrospectively for the influenza season before the intervention and prospectively during the intervention. Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test. RESULTS: At the intervention facility, compliance with five of the guidelines improved: influenza vaccination, timely physician response to illness onset, x-ray for patients not being hospitalized, use of appropriate antibiotics, and timely antibiotic initiation for unstable patients. Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year. CONCLUSION: Multifaceted, evidence-based, NHAP guideline implementation improved care processes in a SVH. Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents.

Which clinical indicators and resident characteristics are associated with health care practitioner nursing home visits or hospital transfer for urinary tract infections?

OBJECTIVES: (1) To determine factors associated with practitioner visitation and/or hospital transfer for skilled nursing facility (SNF) patients who develop a urinary tract infection (UTI) and (2) to determine if SNF patients with a Do Not Resuscitate (DNR) directive are less likely to be personally assessed and/or transferred to the hospital in the event of a UTI when compared to patients without a DNR directive. DESIGN: Retrospective cohort study using nursing home medical record review. PARTICIPANTS: Participants were 564 residents from 35 nursing homes in 3 states who became acutely ill with UTI during the first 90 days of their nursing home admission. They were identified from 2832 random nursing home Medicare admissions and divided into 2 groups, those with DNR directives (n = 334) and those without (n = 230). MEASUREMENTS: Logistic regression was used to determine factors associated with practitioner in-person assessment and/or hospitalization, and to determine differences in the likelihood of practitioner in-person assessment and/or hospitalization among those with DNR directives versus those without DNR directives. RESULTS: Only one third (29%) of patients with unstable vital signs were seen by a practitioner or transferred to a hospital. Factors associated with practitioner assessment or hospital transfer were elevated temperature (OR 1.7, CI 1.04-2.64), pulse more than 100 beats per minute (OR 1.7, CI 1.01-2.99), and delirium (OR 2.1, CI 1.267-3.44). White residents were less likely to be assessed by a practitioner or transferred to a hospital (OR 0.45, CI 0.22-0.95). DNR directives were not significantly associated with fewer in-person assessments (P = .067). CONCLUSION: Only one third of SNF patients who developed a UTI with unstable vital signs were personally assessed by a practitioner and/or hospitalized. Patients with delirium were twice as likely to be assessed or transferred to a hospital, suggesting that practitioners use delirium as an indicator of illness severity. However, practitioner visit or transfer was also associated with ethnic background. In the absence of good evidence regarding which nursing home residents are likely to benefit from hospitalization or an urgent practitioner visit, these care decisions will continue to be associated with factors that are unknown.

Nursing home resident barriers to effective pain management: why nursing home residents may not seek pain medication.

OBJECTIVES: Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior. DESIGN: Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication. SETTING: The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings. PARTICIPANTS: A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices. MEASUREMENTS: A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication. RESULTS: More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P < or = .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P < or = .05). They also tended to be older on average (80.4 +/- 12.1 years vs. 77.9 +/- 12.7 years, P < or = .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P < or = 0.01). CONCLUSION: Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff's motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.

Burdensome Physical and Depressive Symptoms Predict Heart Failure-Specific Health Status Over One Year.

CONTEXT: Heart failure (HF)-specific health status (symptom burden, functional status, and health-related quality of life) is an important patient-reported outcome that is associated with palliative care needs, hospitalizations, and death. OBJECTIVES: To identify potentially modifiable patient-reported factors that predict HF-specific health status over one year. METHODS: This was a prospective cohort study using data from the Patient-Centered Disease Management trial. Participants were identified using population-based sampling of all patients with an HF diagnosis at four VA Medical Centers. Patients were enrolled with reduced HF-specific health status (i.e., significant HF symptoms, limited functional status, and poor quality of life, defined by a Kansas City Cardiomyopathy Questionnaire [KCCQ] score <60). Patient-reported factors at baseline were chest pain, other noncardiac pain, dry mouth, numbness/tingling, constipation, nausea, cough, dizziness, depressive symptoms (Patient Health Questionnaire-9), and spiritual well-being (validated, single-item measure). Patients reported HF-specific health status (KCCQ) at 3, 6, and 12 months. RESULTS: Of 384 U.S. veterans, 42% screened positive for depression and 76% described burdensome physical symptoms at baseline. In bivariate analyses, all patient-reported factors were correlated with KCCQ score over one year. Multivariable mixed-effect modeling showed that baseline chest pain, numbness/tingling, depressive symptoms, and higher comorbidity count predicted HF-specific health status over the following year. CONCLUSION: Burdensome physical and depressive symptoms independently predicted subsequent HF-specific health status in patients with symptomatic HF. Whether addressing these aspects of the patient experience can improve health status and well-being in symptomatic HF should be studied further.

Challenges of Providing End-of-Life Care for Homeless Veterans.

OBJECTIVE: To describe challenges of caring for homeless veterans at end of life (EOL) as perceived by Veterans Affairs Medical Center (VAMC) homeless and EOL care staff. DESIGN: E-mail survey. SETTING/PARTICIPANTS: Homelessness and EOL programs at VAMCs. MEASUREMENTS: Programs and their ratings of personal, structural, and clinical care challenges were described statistically. Homelessness and EOL program responses were compared in unadjusted analyses and using multivariable models. RESULTS: Of 152 VAMCs, 50 (33%) completed the survey. The VAMCs treated an average of 6.5 homeless veterans at EOL annually. Lack of appropriate housing was the most critical challenge. The EOL programs expressed somewhat more concern about lack of appropriate care site and care coordination than did homelessness programs. CONCLUSIONS: Personal, clinical, and structural challenges face care providers for veterans who are homeless at EOL. Deeper understanding of these challenges will require qualitative study of homeless veterans and care providers.

Measuring pain intensity in nursing home residents.

Assessing pain intensity in nursing home residents remains a challenge. As part of a multifaceted intervention study to improve pain practices in nursing homes, quarterly pain assessments were conducted in 12 Colorado nursing homes. Residents who reported pain or discomfort of any kind in the past 24 hours were asked to choose one of three pain intensity scales to quantify their current and highest level of pain intensity. They were also observed for pain behaviors using Feldt's Checklist of Nonverbal Pain Indicators. Residents preferred the Verbal Descriptor Scale almost 2:1 over the 11-point Verbal Numeric Rating Scale and the Faces Pain Scale. Sex and ethnicity were associated with differences in scale preference. More than one-half of residents reporting pain had an observable pain indicator. There was a monotonic relationship between reported pain intensity and number of observed pain indicators. To improve pain assessment and management in nursing homes, residents should be given a choice of pain intensity scales and observed for possible pain behaviors.

Nursing home resident barriers to effective pain management: why nursing home residents may not seek pain medication.

OBJECTIVES: Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior. DESIGN: Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication. SETTING: The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings. PARTICIPANTS: A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices. MEASUREMENTS: A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication. RESULTS: More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P < or = .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P < or = .05). They also tended to be older on average (80.4 +/- 12.1 years vs. 77.9 +/- 12.7 years, P < or = .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P < or = 0.01). CONCLUSION: Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff's motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.

Comparing Survival Following Hip Fracture Repair in VHA and Non-VHA Facilities.

INTRODUCTION: Although postsurgical outcomes are similar between Veterans Health Administration (VHA) and non-VHA hospitals for many procedures, no studies have compared 30-day and 1-year survival following hip fracture repair. Therefore, this study compared survival of veterans aged 65 years and older treated in VHA hospitals with a propensity-matched cohort of Medicare beneficiaries in non-VHA hospitals. MATERIALS AND METHODS: Retrospective cohort study of 1894 hip fracture repair patients in VHA or non-VHA hospitals between 2003 and 2005. Current Procedural Terminology codes identified 3542 male patients aged >65 years who had hip fracture repair between 2003 and 2005 in the Veterans Affairs' National Surgical Quality Improvement Program database. The Medicare comparison sample was drawn from 2003 to 2005 Medicare Part A inpatient hospital claims files. To create comparable VHA and Medicare cohorts, patients were propensity score matched on age, admission source (community vs. nursing home), repair type, comorbidity index, race, year, and region. Thirty-day and 1-year survival after surgery were compared between cohorts after further adjustment for selected comorbidities, year of surgery, and pre- and postsurgical length of hospital stay using logistic regression. RESULTS: Odds of survival were significantly better in the Medicare than the VHA cohort at 30 days (1.68, 95% CI 1.15-2.44) and 1 year (1.35, 95% CI 1.08-1.69). CONCLUSION: Medicare beneficiaries with hip fracture repair in non-VHA hospitals had better survival than veterans in VHA hospitals. Whether this is driven by unobserved patient characteristics or systematic care differences is unknown.

Decisional support to prevent adverse drug reactions of long latency: pilot randomized controlled intervention for glucocorticoid-induced diabetes.

RATIONALE, AIMS, AND OBJECTIVES: Long-term exposure to glucocorticoids can cause adverse drug reactions of long latency (ADRLLs), including glucocorticoid-induced diabetes mellitus (GID). Providers can monitor for GID using the glycosylated haemoglobin blood (HbA1C) test. This study examined the utility of decisional support to improve HbA1C-based screening for GID. US veterans were identified as chronic users of oral glucocorticoids (>120 days of oral glucocorticoids in the last 2 years). The primary care providers caring for these patients were the target of the intervention. Providers were randomized to receive automatic HbA1C orders for their patients receiving chronic glucocorticoid or usual care. METHODS: This study was a pilot two-arm, group-randomized, controlled trial (n = 12 providers, n = 38 patients). Data collection occurred from 5 May 2013 until 10 January 2014. A pharmacist generated the order for an HbA1C through the electronic medical record. The time between the intervention start date and the date on which an HbA1C order was signed were compared using Cox proportional and hierarchical linear regression. RESULTS: The time to sign HbA1C orders (mean 12.0 days for the intervention arm; 104.0 days for control arm) was associated with significant differences favouring the intervention [HR (Hazard Ratio) 50.2, P < 0.001, confidence interval (CI) 6.3 to 398.7]. For the intervention group, 95% of orders were signed, whereas only 12% of control providers signed orders (odds ratio 150, P < 0.001, CI 12.4 to 1812.9). CONCLUSIONS: The results of this study strongly suggest that the clinical pharmacist-triggered order intervention is effective. This method of computerized decisional support may be useful in improving screening for GID and ADRLLs.

Precipitants of emergency room visits and acute hospitalization in short-stay medicare nursing home residents.

OBJECTIVES: To determine what precipitates rehospitalization for residents who become acutely ill in the first 90 days of a nursing home (NH) admission. DESIGN: NH medical record review comparing acutely ill Medicare admissions transferred back to hospital with those not transferred. SETTING: Sixty skilled nursing facilities in five states during 1994. PARTICIPANTS: Six hundred thirty-six residents who became acutely ill with urinary tract infection (UTI), pneumonia, or congestive heart failure (CHF) during the first 90 days of their nursing home admission were identified from 2,414 random NH Medicare admissions, excluding those with orders not to be hospitalized. MEASUREMENTS: Diagnosis, age, gender, advance care directives, nursing shift during which problem occurred, comorbidity, symptoms, and signs of acutely ill NH residents transferred to the hospital or emergency department were compared with those not transferred. RESULTS: Rates of hospitalization varied markedly by acute illness: 11 of residents with UTI, 46 with pneumonia, and 58 with an exacerbation of CHF (P< .001). In stratified multivariate analysis, older age decreased the odds of rehospitalization only for CHF. Male gender increased odds of hospitalization for pneumonia (odds ratio (OR) = 2.94) and decreased odds of hospitalization for CHF (OR = 0.28). Do not resuscitate orders were negatively associated with hospitalization only for pneumonia (OR = 0.23), whereas weekend and evening/night shifts increased odds of hospitalization for UTI. Each illness had its own set of symptoms, signs, and comorbidities associated with hospitalization. CONCLUSIONS: Whether an acutely ill NH Medicare patient was rehospitalized depended primarily on the particular illness. The relative importance of age, gender, shift, advance care directives, symptom severity, signs, and comorbid illnesses varied by diagnosis.

Improving care for nursing home-acquired pneumonia in a managed care environment.

OBJECTIVE: To characterize care of nursing home residents who became ill with nursing home-acquired pneumonia (NHAP) in a group-model, nonprofit HMO, and to pilot-test a strategy to implement evidence-based NHAP care guidelines. STUDY DESIGN: Medical record review and intervention pilot test. METHODS: Nursing home medical records of 78 patients who developed NHAP in 6 homes where the HMO contracts for Medicare services were reviewed for demographics, functional status, comorbidity, NHAP severity, care processes, and guideline compliance. The intervention, combining organizational change (facilitating immunization and providing appropriate emergency antibiotics) and education (quarterly in-services for nursing and aide staff), was pilot-tested for 7 months in 1 facility. Measures of baseline and intervention guideline adherence at that facility were compared with Fisher's exact test. RESULTS: Among the patients with NHAP, 83% had a response from their physician in less than 8 hours, 82% were treated with an antibiotic that met spectrum recommendations, and 74% were able to swallow were treated with oral antibiotics. However, few patients had documentation of influenza and pneumococcal vaccination; less than half the direct care staff had been vaccinated; and nursing assessments were incomplete for 23%. At the pilot-test facility, improvement was seen in influenza vaccination (14% to 52%, P = .01) and use of the most appropriate antibiotics (47% to 85%; P = .03). The guideline adherence score improved from 52% to 63% (P = .04). CONCLUSION: Use of a multidisciplinary, multifaceted intervention resulted in improvement in quality of care for nursing home residents who become ill with pneumonia.

Improving nursing home staff knowledge and attitudes about pain.

PURPOSE: Effective pain management remains a serious problem in the nursing home setting. Barriers to achieving optimal pain practices include staff knowledge deficits, biases, and attitudes that influence assessment and management of the residents' pain. DESIGN AND METHODS: Twelve nursing homes participated in this intervention study: six treatment homes and six control homes, divided evenly between urban and rural locations. Three hundred licensed and unlicensed nursing home staff members completed written knowledge and attitude surveys at baseline, and 378 staff members completed the surveys after intervention implementation. RESULTS: Baseline results revealed notable knowledge deficits in the areas of pharmacology, drug addiction and dependence, side effect management, and nonpharmacologic management-strategy effectiveness. Significant differences were noted by job title (registered nurse/licensed practical nurse/certified nursing assistant). Case studies displayed a knowledge application problem, with nurses often filtering resident pain reports through observed resident behaviors. The intervention led to significant improvement in knowledge scores in some, but not all, the treatment homes. Perceived barriers to effective pain management showed a significant decline across all study nursing homes. IMPLICATIONS: Knowledge deficits related to pain management persist in nursing homes. An interactive multifaceted educational program was only partially successful in improving knowledge across settings and job categories. Attitudes and beliefs appear more difficult to change, whereas environmental and contextual factors appeared to be reducing perceived barriers to effective pain management across all participating nursing homes.

Associations among processes and outcomes of care for Medicare nursing home residents with acute heart failure.

OBJECTIVE: To characterize Medicare skilled nursing facility (SNF) residents who become acutely ill with heart failure (HF) and assess the association between the outcomes of rehospitalization and mortality, and severity of the acute exacerbation, comorbidity, and processes of care. DESIGN: SNF medical record review of Medicare patients who developed an acute exacerbation of heart failure (HF) during the 90 days following nursing home admission. SETTING: A total of 58 SNFs in 5 states during 1994 and 1997. PARTICIPANTS: Patients with 156 episodes of acute HF among 4693 random Medicare nursing home admissions. MEASUREMENTS: Demographic variables, symptoms, signs, comorbidity, nursing home characteristics, nurse staffing ratios, and processes of care were compared between acute HF subjects transferred to hospital and those not transferred; and between subjects who died within 30 days of an acute exacerbation and those who survived. RESULTS: After adjusting for age, disease severity, and comorbidity, residents whose change in condition was evaluated during the night shift were more likely to be hospitalized (OR 4.20, 95%CI 1.01-17.50). Residents who were prescribed an angiotensin-converting enzyme inhibitor or who received an order for skilled nursing observation more often than once a shift were 1/3 as likely to die as those who did not (OR 0.303, 95%CI 0.11-0.82), after adjusting for hypotension, delirium, do not resuscitate orders, and prior hospital length of stay. CONCLUSION: For residents who develop an acute exacerbation of HF during a SNF stay, there is an association between attributes of nursing home care and the outcomes of rehospitalization and mortality.