Communication technology adoption among older adult veterans: the interplay of social and cognitive factors.

OBJECTIVES: InTouch is an electronic communication platform designed to be accessible by computer-naive seniors. The present study explored the process of adoption and use of the application by seniors with and without mild cognitive impairment (MCI) through the lens of Social Cognitive Theory (SCT). METHOD: We studied adoption and use of InTouch for social communication over a 12-week period in a 475-bed Veteran's care facility at Sunnybrook Health Sciences Centre in Toronto, Canada. Eleven older adult veterans participated, six of whom had MCI, as indicated by their Montreal Cognitive Assessment score. Veterans were partnered with volunteers, each was provided with an iPad with the InTouch application. Qualitative data were collected through interviews, field notes, and direct observation. Quantitative data were collected from data logging of the software and medical charts. Data types and sources were triangulated and examined through the lens of SCT. RESULTS: A total of 2361 messages (102 videos, 359 audios, 417 photos, 1438 texts) were sent by 10 of the 11 veterans over the 12-week study period. There was no apparent difference in extent of adoption or use, between participants with and without MCI. Participants used various resources and techniques to learn, provided that they felt motivated to connect with others using the app. CONCLUSION: This pilot illustrates both the accessibility of InTouch and the promise of using extrinsic motivators such as social bonding to promote learning in institutionalized older adults with and without cognitive impairment, whose intrinsic motivation and self-efficacy may well be suffering.

[Novel central dopaminergic agents derived from atypical di-substituted 2-aminoindane-4, 7. Synthesis and central pharmacological profile]. / Novedosos agentes dopaminérgicos centrales derivados del 2-aminoindano-4,7 disustituido atipico. Síntesis y perfil farmacológico central.

In recent decades, many compounds with central dopaminergic activity have been designed, synthesized and evaluated pharmacologically. However, it has not been possible to obtain a drug able to improve or cure diseases involving dopaminergic regulation in the central nervous system, such as Parkinson's disease and schizophrenia, among others. Taking into consideration the term "atypical pharmacophore" and from the compound 5, the aralkyl fragment was incorporated, and the compounds 10, 11, 13a-h and 14a-h were synthesized. Both the compounds 10 and 13a-h under its methoxylated form and the compounds 11 and 14a-h under the phenolic form, were evaluated to determine their pharmacologically agonistic and antagonistic effects on central dopaminergic activity. For this, the effect of intracerebroventricular injection of said compounds on the hydromineral balance and stereotyped behavior in rats, was determined. The results of the preliminary pharmacological evaluation show a centrally acting action through dopamine mechanisms, in which the compounds 10, 11, 13d-h and 14a showed responses as agonists, whereas compounds 14b-h, had responses as antagonists.

Pressure ulcer multidisciplinary teams via telemedicine: a pragmatic cluster randomized stepped wedge trial in long term care.

BACKGROUND: The study was conducted to determine the clinical and cost effectiveness of enhanced multi-disciplinary teams (EMDTs) vs. 'usual care' for the treatment of pressure ulcers in long term care (LTC) facilities in Ontario, Canada METHODS: We conducted a multi-method study: a pragmatic cluster randomized stepped-wedge trial, ethnographic observation and in-depth interviews, and an economic evaluation. Long term care facilities (clusters) were randomly allocated to start dates of the intervention. An advance practice nurse (APN) with expertise in skin and wound care visited intervention facilities to educate staff on pressure ulcer prevention and treatment, supported by an off-site hospital based expert multi-disciplinary wound care team via email, telephone, or video link as needed. The primary outcome was rate of reduction in pressure ulcer surface area (cm2/day) measured on before and after standard photographs by an assessor blinded to facility allocation. Secondary outcomes were time to healing, probability of healing, pressure ulcer incidence, pressure ulcer prevalence, wound pain, hospitalization, emergency department visits, utility, and cost. RESULTS: 12 of 15 eligible LTC facilities were randomly selected to participate and randomized to start date of the intervention following the stepped wedge design. 137 residents with a total of 259 pressure ulcers (stage 2 or greater) were recruited over the 17 month study period. No statistically significant differences were found between control and intervention periods on any of the primary or secondary outcomes. The economic evaluation demonstrated a mean reduction in direct care costs of $650 per resident compared to 'usual care'. The qualitative study suggested that onsite support by APN wound specialists was welcomed, and is responsible for reduced costs through discontinuation of expensive non evidence based treatments. Insufficient allocation of nursing home staff time to wound care may explain the lack of impact on healing. CONCLUSION: Enhanced multi-disciplinary wound care teams were cost effective, with most benefit through cost reduction initiated by APNs, but did not improve the treatment of pressure ulcers in nursing homes. Policy makers should consider the potential yield of strengthening evidence based primary care within LTC facilities, through outreach by APNs. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01232764.

A realist evaluation of value-based care delivery in home care: The influence of actors, autonomy and accountability.

The increasing demand for home care is occurring in tandem with the need for governments to contain health care costs, maximize appropriate resource utilization and respond to patient preferences for where they receive care. We describe the evaluation of the Integrated Client Care Project (ICCP), a government funded project designed to improve value for outcomes for patients referred to community wound care services in Ontario, Canada. We applied a realist evaluation methodology in order to unpack the influences of contextual and mechanistic choices on the intended outcomes of the ICCP implementation. We collected data through ethnographic methods including 36 months of field observation, 46 key informant interviews and contemporaneous document analysis. The findings presented here highlight how theoretical mechanisms were negatively impacted by strong contextual patterns and weak implementation which led to underwhelming outcomes. Autonomy of the participant organizations, lack of power within the implementation team to drive change, opacity of the goals of the program, and disregard for the impact of complex historical relations within the home care sector compounded to undermine the intended outcome.

A large cluster randomized trial of outcome-based pathways to improve home-based wound care.

BACKGROUND: Although not always recognized as a pressing health care problem, wounds are a common, complex and costly condition. The burden of treating wounds is growing rapidly due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide. The Integrated Client Care (ICC) Project was a multi-year initiative to develop and test a new, integrated model of wound care within the home care sector in Ontario, Canada to improve health outcomes for patients and decrease system costs. METHODS: Cluster randomized trial, with allocation of intervention randomized at the cluster level (14 home care centers) and analysis of outcomes based on individual-level data (patients). Primary analysis was an intention-to-treat (ITT) analysis. Two wound types, diabetic foot ulcers and pilonidal sinus, were selected as tracer conditions to assess the impact of the intervention on two different patient populations. Time to successful discharge from home care was analyzed using multivariable Cox proportional hazards regression. Hazard ratios (HRs) and 95% confidence intervals (CIs) are presented. RESULTS: A total of 12,063 diabetic foot ulcer patients and 1954 pilonidal sinus patient records were available for analysis. No appreciable differences were observed between patients in the control and intervention arms for either of the primary or secondary analyses in either condition group. In the diabetic foot ulcer group, 72.7% patients in the control arm and 73.6% patients in the intervention arm were discharged in the follow-up period (HR 1.05; 95% CI 0.94 to 1.17). In the pilonidal sinus group, 91.0% patients in the control arm and 89.0% patients in the intervention arm were discharged in the follow-up period (HR 0.96; 95% CI 0.82 to 1.12). CONCLUSION: As implemented, the ICC intervention was not effective, most likely due to failure of implementation, and is, therefore, not ready for widespread implementation in Ontario. Significant work remains to be done to correct the implementation process so that the concept of outcome-based health care can be properly evaluated. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT01573832 . Registered on 12 January 2012.

Preventing Pressure Ulcers: A Multisite Randomized Controlled Trial in Nursing Homes.

BACKGROUND: Pressure at the interface between bony prominences and support surfaces, sufficient to occlude or reduce blood flow, is thought to cause pressure ulcers (PrUs). Pressure ulcers are prevented by providing support surfaces that redistribute pressure and by turning residents to reduce length of exposure. OBJECTIVE: We aim to determine optimal frequency of repositioning in long-term care (LTC) facilities of residents at risk for PrUs who are cared for on high-density foam mattresses. METHODS: We recruited residents from 20 United States and 7 Canadian LTC facilities. Participants were randomly allocated to 1 of 3 turning schedules (2-, 3-, or 4-hour intervals). The study continued for 3 weeks with weekly risk and skin assessment completed by assessors blinded to group allocation. The primary outcome measure was PrU on the coccyx or sacrum, greater trochanter, or heels. RESULTS: Participants were mostly female (731/942, 77.6%) and white (758/942, 80.5%), and had a mean age of 85.1 (standard deviation [SD] ± 7.66) years. The most common comorbidities were cardiovascular disease (713/942, 75.7%) and dementia (672/942, 71.3%). Nineteen of 942 (2.02%) participants developed one superficial Stage 1 (n = 1) or Stage 2 (n = 19) ulcer; no full-thickness ulcers developed. Overall, there was no significant difference in PrU incidence (P = 0.68) between groups (2-hour, 8/321 [2.49%] ulcers/group; 3-hour, 2/326 [0.61%]; 4-hour, 9/295 [3.05%]. Pressure ulcers among high-risk (6/325, 1.85%) versus moderate-risk (13/617, 2.11%) participants were not significantly different (P = 0.79), nor was there a difference between moderate-risk (P = 0.68) or high-risk allocation groups (P = 0.90). CONCLUSIONS: Results support turning moderate- and high-risk residents at intervals of 2, 3, or 4 hours when they are cared for on high-density foam replacement mattresses. Turning at 3-hour and at 4-hour intervals is no worse than the current practice of turning every 2 hours. Less frequent turning might increase sleep, improve quality of life, reduce staff injury, and save time for such other activities as feeding, walking, and toileting.

Turning for Ulcer Reduction (TURN) Study: An Economic Analysis.

BACKGROUND: The Turning for Ulcer Reduction (TURN) study was a multisite, randomized controlled trial that aimed to determine the optimal frequency of turning nursing facility residents with mobility limitations who are at moderate and high risk for pressure ulcer (PrU) development. Here we present data from the economic analysis. OBJECTIVES: This economic analysis aims to estimate the economic consequences for Ontario of switching from a repositioning schedule of 2-hour intervals to a schedule of 3-hour or 4-hour intervals. DATA SOURCES: Costs considered in the analysis included those associated with nursing staff time spent repositioning residents and with incontinent care supplies, which included briefs, barrier cream, and washcloths. RESULTS: The total economic benefit of switching to 3-hour or 4-hour repositioning is estimated to be $11.05 or $16.74 per day, respectively, for every resident at moderate or high risk of developing PrUs. For a typical facility with 123 residents, 41 (33%) of whom are at moderate or high risk of developing PrUs, the total economic benefit is estimated to be $453 daily for 3-hour or $686 daily for 4-hour repositioning. For Ontario as a whole, assuming that there are 77,933 residents at 634 LTC facilities, 25,927 (33%) of whom are at moderate or high risk of developing PrUs, the total economic benefits of switching to 3-hour or 4-hour repositioning are estimated to be $286,420 or $433,913 daily, respectively, equivalent to $104.5 million or $158.4 million per year. LIMITATIONS: We did not consider the savings the Ontario Ministry of Health and Long-Term Care might incur should less frequent repositioning reduce the incidence of work-related injury among nursing staff, so our findings are potentially conservative. CONCLUSIONS: A switch to 3-hour or 4-hour repositioning appears likely to yield substantial economic benefits to Ontario without placing residents at greater risk of developing PrUs.

Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes.

OBJECTIVES: To determine optimal repositioning frequency of nursing home (NH) residents at risk for pressure ulcers (PrUs) when cared for on high-density foam mattresses. DESIGN: Multisite, randomized, clinical trial, known as Turning for Ulcer ReductioN (TURN Study). SETTINGS: NHs in the United States (n = 20) and Canada (n = 7) using high-density foam mattresses. PARTICIPANTS: Consenting residents (N = 942) aged 65 and older without PrUs at moderate (scores 13-14) or high (scores 10-12) risk of PrUs according to the Braden Scale. INTERVENTION: Participants were randomly allocated using risk stratification (moderate vs high) to a repositioning schedule (2, 3, or 4 hour) for 3 weeks. Blinded assessors assessed skin weekly. MEASUREMENTS: PrU incidence (coccyx or sacrum, trochanter, heels). RESULTS: Participants were mostly female (77.6%) and Caucasian (80.5%) and had a mean age of 85.1 ± 7.7. The most common diagnoses were cardiovascular (76.9%) and dementia (72.5%). Nineteen (2.0%) participants developed superficial PrUs. There was no significant difference (Wilcoxon test for ordered categories) in PrU incidence (P = .68) according to repositioning group (2 hour, 8/321, 2.5%; 3 hour, 2/326, 0.6%; 4 hour, 9/295, 3.1%), nor was there a statistically significant difference in the incidence of PrU between the high and moderate-risk groups (P = .79). Also, PrU incidence was not statistically significantly different between high-risk participants based on repositioning schedule (6/325, 1.8%, P = .90) or between moderate-risk participants based on repositioning schedule (13/617, 2.1%, P = .68). CONCLUSION: There was no difference in PrU incidence over 3 weeks of observation between those turned at 2-, 3-, or 4-hour intervals in this population of residents using high-density foam mattresses at moderate and high risk of developing PrUs when they were repositioned consistently and skin was monitored. This finding has major implications for use of nursing staff and cost of NH care.

Use of home telehealth in palliative cancer care: a case study.

We conducted a mixed-methods case study to explore the perceptions of family caregivers and palliative cancer patients of home telehealth, and their experience with it. The intervention in the randomized controlled trial from which study participants were selected consisted of specialist nurses available 24 hours per day who communicated with patients and families using videophones, with optional remote monitoring. Qualitative data were collected from interviews with five patient/caregiver dyads and seven bereaved family caregivers, direct observation and nursing documentation. Quantitative data were collected from computerized nursing documentation and analyzed for patterns of use. During the study there were 255 contacts, including videophone, telephone or face-to-face visits, between tele-nurses and families. Overall the patients, family caregivers and tele-nurses felt that home telehealth enabled family caregiving, citing increased access to care, and patient and family caregiver reassurance. Pain management was the most common reason for initiating contact with the nurse, followed by emotional support. Concerns included lack of integration of services, inappropriate timing of the intervention and technical problems. The case study confirmed the importance of timely and accessible care for a group of clinically vulnerable, dying cancer patients and their family caregivers.

Preventing pressure ulcers in long-term care: a cost-effectiveness analysis.

BACKGROUND: Pressure ulcers are common in many care settings, with adverse health outcomes and high treatment costs. We evaluated the cost-effectiveness of evidence-based strategies to improve current prevention practice in long-term care facilities. METHODS: We used a validated Markov model to compare current prevention practice with the following 4 quality improvement strategies: (1) pressure redistribution mattresses for all residents, (2) oral nutritional supplements for high-risk residents with recent weight loss, (3) skin emollients for high-risk residents with dry skin, and (4) foam cleansing for high-risk residents requiring incontinence care. Primary outcomes included lifetime risk of stage 2 to 4 pressure ulcers, quality-adjusted life-years (QALYs), and lifetime costs, calculated according to a single health care payer's perspective and expressed in 2009 Canadian dollars (Can$1 = US$0.84). RESULTS: Strategies cost on average $11.66 per resident per week. They reduced lifetime risk; the associated number needed to treat was 45 (strategy 1), 63 (strategy 4), 158 (strategy 3), and 333 (strategy 2). Strategy 1 and 4 minimally improved QALYs and reduced the mean lifetime cost by $115 and $179 per resident, respectively. The cost per QALY gained was approximately $78 000 for strategy 3 and $7.8 million for strategy 2. If decision makers are willing to pay up to $50 000 for 1 QALY gained, the probability that improving prevention is cost-effective is 94% (strategy 4), 82% (strategy 1), 43% (strategy 3), and 1% (strategy 2). CONCLUSIONS: The clinical and economic evidence supports pressure redistribution mattresses for all long-term care residents. Improving prevention with perineal foam cleansers and dry skin emollients appears to be cost-effective, but firm conclusions are limited by the available clinical evidence.

Health related virtual communities and electronic support groups: systematic review of the effects of online peer to peer interactions.

OBJECTIVE: To compile and evaluate the evidence on the effects on health and social outcomes of computer based peer to peer communities and electronic self support groups, used by people to discuss health related issues remotely. DESIGN AND DATA SOURCES: Analysis of studies identified from Medline, Embase, CINAHL, PsycINFO, Evidence Based Medicine Reviews, Electronics and Communications Abstracts, Computer and Information Systems Abstracts, ERIC, LISA, ProQuest Digital Dissertations, Web of Science. SELECTION OF STUDIES: We searched for before and after studies, interrupted time series, cohort studies, or studies with control groups; evaluating health or social outcomes of virtual peer to peer communities, either as stand alone interventions or in the context of more complex systems with peer to peer components. MAIN OUTCOME MEASURES: Peer to peer interventions and co-interventions studied, general characteristics of studies, outcome measures used, and study results. RESULTS: 45 publications describing 38 distinct studies met our inclusion criteria: 20 randomised trials, three meta-analyses of n of 1 trials, three non-randomised controlled trials, one cohort study, and 11 before and after studies. Only six of these evaluated "pure" peer to peer communities, and one had a factorial design with a "peer to peer only" arm, whereas 31 studies evaluated complex interventions, which often included psychoeducational programmes or one to one communication with healthcare professionals, making it impossible to attribute intervention effects to the peer to peer community component. The outcomes measured most often were depression and social support measures; most studies did not show an effect. We found no evidence to support concerns over virtual communities harming people. CONCLUSIONS: No robust evidence exists of consumer led peer to peer communities, partly because most peer to peer communities have been evaluated only in conjunction with more complex interventions or involvement with health professionals. Given the abundance of unmoderated peer to peer groups on the internet, research is required to evaluate under which conditions and for whom electronic support groups are effective and how effectiveness in delivering social support electronically can be maximised.