Building Pandemic-Resilient Primary Care Systems: Lessons Learned From COVID-19.

On January 30, 2023, the Biden Administration announced its intention to end the existing COVID-19 public health emergency declaration. The transition to a "postpandemic" landscape presents a unique opportunity to sustain and strengthen pandemic-era changes in care delivery. With this in mind, we present 3 critical lessons learned from a primary care perspective during the COVID-19 pandemic. First, clinical workflows must support both in-person and internet-based care delivery. Second, the integration of asynchronous care delivery is critical. Third, planning for the future means planning for everyone, including those with potentially limited access to health care due to barriers in technology and communication. While these lessons are neither unique to primary care settings nor all-encompassing, they establish a grounded foundation on which to construct higher-quality, more resilient, and more equitable health systems.

Nursing Home PRevention of Injury in DEmentia (NH PRIDE): A pilot study of a remote injury prevention service for NH residents.

BACKGROUND: Medication optimization, including prescription of osteoporosis medications and deprescribing medications associated with falls, may reduce injurious falls. Our objective was to describe a remote, injury prevention service (NH PRIDE) designed to optimize medication use in nursing homes (NHs), and to describe its implementation outcomes in a pilot study. METHODS: This was a non-randomized trial (pilot study) including NH staff and residents from five facilities. Long-stay residents at high-risk for injurious falls were identified using a validated risk calculator and staff referral. A remote team reviewed the electronic health record (EHR) and provided recommendations as Injury Prevention Plans (IPP). A research nurse served as a care coordinator focused on resident engagement and shared decision-making. Outcomes included implementation measures, as identified in the EHR, and surveys and interviews with staff. RESULTS: Across five facilities, 274 residents were screened for eligibility, and 46 residents (16.8%) were enrolled. Most residents were female (73.9%) and had dementia (63.0%). An IPP was completed for 45 residents (97.8%). The nurse made a total of 93 deprescribing recommendations in 36 residents (80% of residents had one or more deprescribing recommendation; mean 2.2 recommendations/resident). Twenty of 45 residents (44.4%) had a recommendation for osteoporosis treatment. Among residents with recommendations, 21/36 (58.3%) had one or more deprescribing orders written and 6/20 (30.0%) had an osteoporosis medication prescribed. At 4 months, most medication changes persisted. Adverse side effects were rare. Staff members identified several areas for program refinement, including aligning recommendations with provider workflow and engaging consultant psychiatrists. CONCLUSIONS: A remote injury prevention service is safe and feasible to enhance deprescribing and osteoporosis treatment in long-stay NH residents at risk for injury. Additional investigation is needed to determine if this model could reduce injurious falls when deployed across NH chains.

Accumulation in Visceral Adipose Tissue Over 6 Years Is Associated With Lower Paraspinal Muscle Density.

CONTEXT: Visceral adipose tissue (VAT) has been recognized to be a metabolically active fat depot that may have paracrine effects on surrounding tissues, including muscle. Since many adults accumulate VAT as they age, the effect of changes in VAT on muscle is of interest. OBJECTIVE: We determined the association between 6-year changes in VAT and paraspinal muscle density, an indicator of fatty infiltration. METHODS: This study included 1145 participants from the Framingham Study third-generation cohort who had both quantitative computed tomography scans of the spine at baseline and 6-year's follow-up, on whom muscle density was measured along with VAT. We implemented multiple regression to determine the association of muscle density at follow-up as primary outcome measure with changes in VAT (follow-up minus baseline divided by 100), adjusting for VAT at baseline, age, sex, height, menopausal status, presence of diabetes, and physical activity. Analyses were performed in men and women separately. RESULTS: After adjustment for covariates, individuals with the greatest accumulation of VAT over 6 years had significantly lower paraspinal density at the follow-up with an estimated 0.302 (95% CI, -0.380 to -0.224) and 0.476 (95% CI: -0.598 to -0.354) lower muscle density (HU) per 100-cm3 increase in VAT (both P values < .001) in men and women, respectively. CONCLUSION: These results highlight that age-related accumulation of VAT in men and women is associated with lower muscle density. VAT may represent a modifiable risk factor for poor musculoskeletal outcomes with aging.

The Trial to Reduce Antimicrobial Use in Nursing Home Residents With Alzheimer Disease and Other Dementias (TRAIN-AD): A Cluster Randomized Clinical Trial.

Importance: Antimicrobials are extensively prescribed to nursing home residents with advanced dementia, often without evidence of infection or consideration of the goals of care. Objective: To test the effectiveness of a multicomponent intervention to improve the management of suspected urinary tract infections (UTIs) and lower respiratory infections (LRIs) for nursing home residents with advanced dementia. Design, Setting, and Participants: A cluster randomized clinical trial of 28 Boston-area nursing homes (14 per arm) and 426 residents with advanced dementia (intervention arm, 199 residents; control arm, 227 residents) was conducted from August 1, 2017, to April 30, 2020. Interventions: The intervention content integrated best practices from infectious diseases and palliative care for management of suspected UTIs and LRIs in residents with advanced dementia. Components targeting nursing home practitioners (physicians, physician assistants, nurse practitioners, and nurses) included an in-person seminar, an online course, management algorithms (posters, pocket cards), communication tips (pocket cards), and feedback reports on prescribing of antimicrobials. The residents' health care proxies received a booklet about infections in advanced dementia. Nursing homes in the control arm continued routine care. Main Outcomes and Measures: The primary outcome was antimicrobial treatment courses for suspected UTIs or LRIs per person-year. Outcomes were measured for as many as 12 months. Secondary outcomes were antimicrobial courses for suspected UTIs and LRIs when minimal criteria for treatment were absent per person-year and burdensome procedures used to manage these episodes (bladder catherization, chest radiography, venous blood sampling, or hospital transfer) per person-year. Results: The intervention arm had 199 residents (mean [SD] age, 87.7 [8.0] years; 163 [81.9%] women; 36 [18.1%] men), of which 163 (81.9%) were White and 27 (13.6%) were Black. The control arm had 227 residents (mean [SD] age, 85.3 [8.6] years; 190 [83.7%] women; 37 [16.3%] men), of which 200 (88.1%) were White and 22 (9.7%) were Black. There was a 33% (nonsignificant) reduction in antimicrobial treatment courses for suspected UTIs or LRIs per person-year in the intervention vs control arm (adjusted marginal rate difference, -0.27 [95% CI, -0.71 to 0.17]). This reduction was primarily attributable to reduced antimicrobial use for LRIs. The following secondary outcomes did not differ significantly between arms: antimicrobials initiated when minimal criteria were absent, bladder catheterizations, venous blood sampling, and hospital transfers. Chest radiography use was significantly lower in the intervention arm (adjusted marginal rate difference, -0.56 [95% CI, -1.10 to -0.03]). In-person or online training was completed by 88% of the targeted nursing home practitioners. Conclusions and Relevance: This cluster randomized clinical trial found that despite high adherence to the training, a multicomponent intervention promoting goal-directed care for suspected UTIs and LRIs did not significantly reduce antimicrobial use among nursing home residents with advanced dementia. Trial Registration: ClinicalTrials.gov Identifier: NCT03244917.

An advance care planning long-term care initiative in response to COVID-19.

OBJECTIVE: Describe a systematic approach to address advance care planning (ACP) during a COVID-19 outbreak and its impact on the incidence of new do-not-hospitalize (DNH) directives among long-term care (LTC) residents. DESIGN: Prospective quality improvement initiative. SETTING: Two long-term chronic care campuses within a large academic healthcare organization. PARTICIPANTS: LTC residents with activated healthcare proxies who lacked DNH directives based on documentation in the electronic medical record (EMR) as of April 13, 2020. INTERVENTION: Using a structured discussion guide, trained healthcare staff from various disciplines contacted the residents' proxies to conduct COVID-19 focused ACP discussions. Residents without DNH directives with COVID-19 were prioritized. Preferences ascertained in the discussion were communicated to the residents' primary care teams and directives were updated in the EMR accordingly. MEASUREMENTS: Residents who acquired a new DNH directive during the study initiative were determined using the EMR. Subsequent changes in DNH orders, hospitalizations, and deaths were ascertained by retrospective chart review from the date of new DNH through August 5, 2020. RESULTS: At baseline, 315/581 (54%) of LTC residents did not have a DNH directive. Their mean age was 87 (±9) years and 70% were female. Following ACP discussions, 124/315 (39%) of residents acquired a new DNH directive. Among residents with new DNH directives, 65/124 (52%) were diagnosed with COVID-19 from April 2, 2020 to May 21, 2020. During follow-up, only 6/124 (4.8%) residents had their DNH order reversed, 2/124 (1.6%) residents were hospitalized with illnesses unrelated to COVID-19, and 29/124 (23%) died. CONCLUSIONS: There was substantial opportunity to increase the proportion of LTC residents with DNH orders during the COVID-19 pandemic through a systematic ACP initiative which utilized real-time EMR data. New directives to avoid hospitalizations were sustained among the majority of residents beyond the peak of the pandemic.

The Impact of Tai Chi Exercise on Health Care Utilization and Imputed Cost in Residents of Low-Income Senior Housing.

BACKGROUND/OBJECTIVES: This study was designed to test the impact of Tai Chi (TC) on healthcare utilization and cost in older adults living in low-income senior housing. We hypothesized that TC would improve overall health enough to reduce the use of emergency department (ED) and inpatient services. DESIGN: Cluster randomized controlled trial with randomization at the housing site level. SETTING: Greater Boston, Massachusetts. PARTICIPANTS: The study includes 6 sites with 75 individuals in the TC treatment condition and 6 sites with 67 individuals in the health education control condition. INTERVENTION: Members of the treatment group received up to a year-long intervention with twice weekly, in-person TC exercise sessions along with video-directed exercises that could be done independently at home. The comparison group received monthly, in-person healthy aging education classes (HE). Study recruitment took place between August, 2015 and October, 2017. Key outcomes included acute care utilization (inpatient stays, observation stays and emergency department visits). In addition, the cost of utilization was estimated using the age, sex and race adjusted allowed amount from Medicare claims for a geographically similar population aged ≥ 65. RESULTS: The results suggested a possible reduction in the rate of ED visits in the TC group vs. controls (rate ratio = 0.476, p-value = 0.06), but no findings achieved statistical significance. Adjusted estimates of imputed costs of ED and hospital care were similar between TC and HE, averaging approximately $3,000 in each group. CONCLUSION: ED utilization tended to be lower over 6 to 12 months of TC exercises compared to HE in older adults living in low-income housing, although estimated costs of care were similar.

Increased Clinician Time Using Electronic Health Records During COVID-19 Pandemic.

The COVID-19 pandemic challenged how healthcare systems provided care in socially distanced formats. We hypothesized that the COVID-19 era changes in clinical care delivery models contributed to increased Electronic Health Record (EHR) related work. To evaluate the changes in time and volume metrics of EHR usage, we segregated EHR audit log metric data into PreCOVID2019 March/April/May, initial COVID2020 March/April/May, and late COVID2021 March/April/May for 1262 physician providers. We discovered significant and pragmatically meaningful increases in total average time providers spent in the EHR in minutes mean(SD) PreCOVID2019=1958(1576), Mid-COVID2020=1709(1473), Late-COVID2021=2007(1563). Differences in total time in the EHR were significant Pre-mid:p-value=<0.001, but not Pre-Late:p=0.439. Total number of messages received across all specialties increased significantly mean(SD) PreCOVID=459(389), MidCOVID=400(362), LateCOVID 521(423) Pre-Mid p-value=<0.001 and Pre-Late p-value=<0.001. We additionally found changes in total time to differ significantly across select specialties. Based on these findings we recommend further assessment of physician workload and how new factors such as telehealth are contributing to EHR usage.

The trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias: study protocol for a cluster randomized controlled trial.

BACKGROUND: Infections are common in nursing home (NH) residents with advanced dementia but are often managed inappropriately. Antimicrobials are extensively prescribed, but frequently with insufficient evidence to support a bacterial infection, promoting the emergence of multidrug-resistant organisms. Moreover, the benefits of antimicrobials remain unclear in these seriously ill residents for whom comfort is often the goal of care. Prior NH infection management interventions evaluated in randomized clinical trials (RCTs) did not consider patient preferences and lack evidence to support their effectiveness in 'real-world' practice. METHODS: This report presents the rationale and methodology of TRAIN-AD (Trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias), a parallel group, cluster RCT evaluating a multicomponent intervention to improve infection management for suspected urinary tract infections (UTIs) and lower respiratory tract infections (LRIs) among NH residents with advanced dementia. TRAIN-AD is being conducted in 28 facilities in the Boston, USA, area randomized in waves using minimization to achieve a balance on key characteristics (N = 14 facilities/arm). The involvement of the facilities includes a 3-month start-up period and a 24-month implementation/data collection phase. Residents are enrolled during the first 12 months of the 24-month implementation period and followed for up to 12 months. Individual consent is waived, thus almost all eligible residents are enrolled (target sample size, N = 410). The intervention integrates infectious disease and palliative care principles and includes provider training delivered through multiple modalities (in-person seminar, online course, management algorithms, and prescribing feedback) and an information booklet for families. Control facilities employ usual care. The primary outcome, abstracted from the residents' charts, is the number of antimicrobial courses prescribed for UTIs and LRIs per person-year alive. DISCUSSION: TRAIN-AD is the first cluster RCT testing a multicomponent intervention to improve infection management in NH residents with advanced dementia. Its findings will provide an evidence base to support the benefit of a program addressing the critical clinical and public health problem of antimicrobial misuse in these seriously ill residents. Moreover, its hybrid efficacy-effectiveness design will inform the future conduct of cluster RCTs evaluating nonpharmacological interventions in the complex NH setting in a way that is both internally valid and adaptable to the 'real-world'. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03244917 . Registered on 10 August 2017.

A Cluster Randomized Trial of Tai Chi vs Health Education in Subsidized Housing: The MI-WiSH Study.

OBJECTIVES: Tai Chi (TC) may benefit older adults with a variety of diseases and disabilities. We tested the hypothesis that TC improves physical function in older adults living in low-income housing facilities. DESIGN: Cluster randomized controlled trial. SETTING: Subsidized housing facilities in Boston, Massachusetts, and neighboring communities. PARTICIPANTS: Volunteers were recruited from 15 facilities. The 180 randomized participants were 60 years of age or older, able to understand English and participate in TC, expected to remain in the facility for 1 year, and able to walk independently. INTERVENTION: TC classes were conducted in the housing facilities twice/week for 1 year and compared with monthly health promotion educational classes and social calls. MEASUREMENTS: The primary outcome was physical function measured by the Short Physical Performance Battery (SPPB). Secondary outcomes included other aspects of physical and cognitive function, and falls. RESULTS: An interim analysis revealed less improvement over 12 months in SPPB scores among TC participants (+.20 units; 95% confidence interval [CI] = -.20 to +.60; P = .69) vs control participants (+.51 units; 95% CI = +.15 to +.87; P = .007), a difference of -.31 units (95% CI = -.66 to .04; P = .082). This met the criterion for futility, and the Data Safety Monitoring Board recommended trial termination. No differences were found in 6- or 12-month changes favoring TC in any secondary outcomes or adverse events. CONCLUSION: In older adults with multiple chronic conditions living in subsidized housing facilities, 6 and 12 months of twice/week TC classes were not associated with improvements in functional health. J Am Geriatr Soc 67:1812-1819, 2019.

Contrasting lengths of Pelargonium floral nectar tubes result from late differences in rate and duration of growth.

Background and Aims: Much of morphological evolution in flowers has arisen from pollinator-mediated selection, often manifest as a match between the length of the pollinator's proboscis and the depth of tubular corollas or spurs. We investigate development, growth and homology of the unique nectar tube of Pelargonium, frequently described as 'a spur adnate to the pedicel'. Methods: We focused on two species. The nectar tube of P. ionidiflorum is three times longer than that of P. odoratissimum. Light and scanning electron microscopy were carried out, and daily growth measurements were used to compare nectar tube development and vascular patterns. Key Results: Nectar tubes in both species are initiated centripetally to the dorsal sepal in a space created by lateral displacement of two antepetalous stamens. The cavity deepens through subsequent intercalary growth of the receptacle that proceeds at the same rate in both species until tubes reach approx. 10 mm in length. Differences in final nectar tube lengths arise via an increase in the rate and duration of growth of the receptacle that begins just before anthesis (floral opening) and continues for several days past anthesis in P. ionidiflorum but does not occur in P. odoratissimum. Epidermal cells of the dorsal surface of the nectar tube in P. ionidiflorum are approx. 1.6 times longer than those in P. odoratissimum. Histological sections show no evidence that the nectar tube is a spur that became evolutionarily fused to the pedicel. Conclusions: Nectar tubes in Pelargonium are localized cavities that form in the receptacle via intercalary growth. Differences in the rate and duration of growth just prior to and following anthesis underlie differences in final tube lengths. Because differences in cell lengths do not fully account for differences in nectar tube lengths, evolutionary diversification must involve changes in both cell cycle and cell expansion.

Can ultrasound be used as the primary imaging in children with suspected Crohn disease?

BACKGROUND: There is growing literature on the use of ultrasound (US) for evaluation of Crohn disease in adults, but few studies have been conducted on children. Several studies demonstrated high accuracy of US in the diagnosis of Crohn disease. Using US as the primary screening imaging modality for Crohn disease can reduce health care costs, the need for sedation and ionizing radiation exposure. OBJECTIVE: The aim of our study is to determine if US can be used for screening evaluation of pediatric Crohn disease. MATERIALS AND METHODS: A prospective cohort study of pediatric patients undergoing MR enterography (MRE) for suspected or known history of Crohn disease was performed, with gray-scale and Doppler US of the terminal ileum done immediately before or after MRE. US images were interpreted by two radiologists (Reader 1 and Reader 2) not involved in image acquisition, in blinded and randomized fashion. US findings of Crohn disease including bowel wall thickening, wall stratification, increased vascularity on Doppler, lymphadenopathy, fat infiltration and extraintestinal complications were evaluated. MRE findings of terminal ileitis were considered the reference standard. Demographic data, body mass index (BMI), symptoms, and laboratory, endoscopic and histopathological data were obtained from electronic medical records. RESULTS: Forty-one patients (mean age: 13.7 years: 4.6-18.9 years) were evaluated. Mean BMI was 21.2 (range: 13-40.2); 10 patients (24.3%) were either overweight or obese. Final diagnoses were Crohn disease (n=24), ulcerative colitis (n=4) and normal/non-inflammatory bowel disease-related diagnoses (n=13). US demonstrated sensitivity of 67% and 78% and specificity of 78% and 83%, by Reader 1 and Reader 2, respectively. MRE sensitivity and specificity were 75% and 100%, respectively, compared to final clinicopathological diagnosis. Interobserver agreement between Reader 1 and Reader 2 was good (0.6< kappa <0.8). CONCLUSION: In screening for Crohn disease in children, US has limited sensitivity for detecting terminal ileitis.

Frailty, Physical Activity, and Mobility in Patients With Cardiac Implantable Electrical Devices.

BACKGROUND: This study aimed to demonstrate the feasibility of measuring frailty in patients with cardiac implantable electrical devices while validating the physiologic significance of device-detected physical activity by evaluating its association with frailty and mobility. METHODS AND RESULTS: Outpatients with cardiac implantable electrical devices compatible with physical activity analysis with at least 7 days of data were eligible. Office testing included frailty status (Study of Osteoporotic Fractures instrument), gait speed (m/s), mobility according to the Timed Up and Go (TUG) test (seconds), and daily physical activity (h/d) as measured by cardiac implantable electrical device. Among 219 patients, Study of Osteoporotic Fractures testing found 39.7% to be robust, 47.5% prefrail, and 12.8% frail. The mean gait speed for the cohort was 0.8±0.3 m/s, mean TUG time was 10.9±4.4 seconds, and mean activity was 2.8±1.9 h/d. Frail patients were markedly more likely to have gait speeds <0.8 m/s (OR 6.25, 95% CI 1.79-33.3). In unadjusted analyses each 1-hour increase in mean daily activity was associated with a 46% reduction of frail phenotype (OR 0.54, 95% CI 0.40-0.74) versus robust and with a 27% reduction in the odds of having the prefrail phenotype (OR 0.73, 95% CI 0.62-0.86). After adjustment this association per hour of activity persisted, with an adjusted OR for frailty of 0.71 (95% CI 0.51-0.99) and adjusted OR for prefrailty of 0.81 (95% CI 0.67-0.99). CONCLUSIONS: Frailty and mobility limitation are common among cardiac implantable electrical device patients and are correlated to device-detected physical activity.

Modelling amorphous computations with transcription networks.

The power of electronic computation is due in part to the development of modular gate structures that can be coupled to carry out sophisticated logical operations and whose performance can be readily modelled. However, the equivalences between electronic and biochemical operations are far from obvious. In order to help cross between these disciplines, we develop an analogy between complementary metal oxide semiconductor and transcriptional logic gates. We surmise that these transcriptional logic gates might prove to be useful in amorphous computations and model the abilities of immobilized gates to form patterns. Finally, to begin to implement these computations, we design unique hairpin transcriptional gates and then characterize these gates in a binary latch similar to that already demonstrated by Kim et al. (Kim, White & Winfree 2006 Mol. Syst. Biol. 2, 68 (doi:10.1038/msb4100099)). The hairpin transcriptional gates are uniquely suited to the design of a complementary NAND gate that can serve as an underlying basis of molecular computing that can output matter rather than electronic information.