Agreement and prognostic accuracy of three ED vulnerability screeners: findings from a prospective multi-site cohort study.

OBJECTIVES: To evaluate the agreement between three emergency department (ED) vulnerability screeners, including the InterRAI ED Screener, ER2, and PRISMA-7. Our secondary objective was to evaluate the discriminative accuracy of screeners in predicting discharge home and extended ED lengths-of-stay (> 24 h). METHODS: We conducted a nested sub-group study using data from a prospective multi-site cohort study evaluating frailty in older ED patients presenting to four Quebec hospitals. Research nurses assessed patients consecutively with the three screeners. We employed Cohen's Kappa to determine agreement, with high-risk cut-offs of three and four for the PRISMA-7, six for the ER2, and five for the interRAI ED Screener. We used logistic regression to evaluate the discriminative accuracy of instruments, testing them in their dichotomous, full, and adjusted forms (adjusting for age, sex, and hospital academic status). RESULTS: We evaluated 1855 older ED patients across the four hospital sites. The mean age of our sample was 84 years. Agreement between the interRAI ED Screener and the ER2 was fair (K = 0.37; 95% CI 0.33-0.40); agreement between the PRISMA-7 and ER2 was also fair (K = 0.39; 95% CI = 0.36-0.43). Agreement between interRAI ED Screener and PRISMA-7 was poor (K = 0.19; 95% CI 0.16-0.22). Using a cut-off of four for PRISMA-7 improved agreement with the ER2 (K = 0.55; 95% CI 0.51-0.59) and the ED Screener (K = 0.32; 95% CI 0.2-0.36). When predicting discharge home, the concordance statistics among models were similar in their dichotomous (c = 0.57-0.61), full (c = 0.61-0.64), and adjusted forms (c = 0.63-0.65), and poor for all models when predicting extended length-of-stay. CONCLUSION: ED vulnerability scores from the three instruments had a fair agreement and were associated with important patient outcomes. The interRAI ED Screener best identifies older ED patients at greatest risk, while the PRISMA-7 and ER2 are more sensitive instruments.

RéSUMé: OBJECTIFS: Évaluer la concordance entre trois outils de dépistage de la vulnérabilité des urgences, notamment l'InterRAI ED Screener, ER2 et PRISMA-7. Notre objectif secondaire était d'évaluer la précision discriminative des agents de dépistage dans la prédiction de la sortie à domicile et des durées de séjour prolongées à l'urgence (> 24 heures). MéTHODES: Nous avons mené une étude de sous-groupe emboîtée à partir des données d'une étude de cohorte prospective multi-sites évaluant la fragilité chez les patients plus âgés se présentant aux urgences de quatre hôpitaux québécois. Les infirmières de recherche ont évalué les patients consécutivement avec les trois dépisteurs. Nous avons utilisé le Kappa de Cohen pour déterminer la concordance, avec des seuils de risque élevé de trois et quatre pour le PRISMA-7, de six pour l'ER2 et de cinq pour l' interRAI ED Screener. Nous avons utilisé la régression logistique pour évaluer la précision discriminante des instruments, en les testant dans leur forme dichotomique, complète et ajustée (en ajustant pour l'âge, le sexe et le statut académique). RéSULTATS: Nous avons évalué 1 855 patients âgés aux urgences dans les quatre sites hospitaliers. L'âge moyen de notre échantillon était de 84 ans. La concordance entre l'interRAI ED Screener et l'ER2 était équitable (K =0,37 ; IC à 95 % =0,33-0,40) ; la concordance entre le PRISMA-7 et l'ER2 était également équitable (K = 0,39 ; IC à 95 % =0,36-0,43). La concordance entre interRAI ED Screener et PRISMA-7 était faible (K = 0,19 ; IC à 95 % = 0,16-0,22). L'utilisation d'un seuil de quatre pour PRISMA-7 a amélioré la concordance avec l'ER2 (K =0,55 ; IC à 95% =0,51-0,59) et l'ED Screener (K =0,32 ; IC à 95 % =0,2-0,36). En ce qui concerne la prédiction du retour à domicile, les statistiques de concordance entre les modèles étaient similaires dans leurs formes dichotomiques (c = 0,57-0,61), complètes (c =0,61-0,64) et ajustées (c =0,63-0,65), et faibles pour tous les modèles en ce qui concerne la prédiction de la durée de séjour prolongée. CONCLUSION: Les scores de vulnérabilité aux urgences des trois instruments concordaient assez bien et étaient associés à des résultats importants pour les patients.

Prevalence and predictors of influenza vaccination in long-term care homes: a cross-national retrospective observational study.

OBJECTIVE: To compare facility-level influenza vaccination rates in long-term care (LTC) homes from four countries and to identify factors associated with influenza vaccination among residents. DESIGN AND SETTING: Retrospective cross-sectional study of individuals residing in LTC homes in New Brunswick (Canada), New Zealand, Switzerland, and the Netherlands between 2017 and 2020. PARTICIPANTS: LTC home residents assessed with interRAI assessment system instruments as part of routine practice in New Brunswick (n=7006) and New Zealand (n=34 518), and national pilot studies in Switzerland (n=2760) and the Netherlands (n=1508). End-of-life residents were excluded from all country cohorts. OUTCOMES: Influenza vaccination within the past year. RESULTS: Influenza vaccination rates among LTC home residents were highest in New Brunswick (84.9%) and lowest in Switzerland (63.5%). For all jurisdictions where facility-level data were available, substantial interfacility variance was observed. There was approximately a fourfold difference in the coefficient of variation for facility-level vaccination rates with the highest in Switzerland at 37.8 and lowest in New Brunswick at 9.7. Resident-level factors associated with vaccine receipt included older age, severe cognitive impairment, medical instability, health conditions affecting a greater number of organ systems and social engagement. Residents who displayed aggressive behaviours and smoke tobacco were less likely to be vaccinated. CONCLUSION: There are opportunities to increase influenza vaccine uptake at both overall country and individual facility levels. Enhanced vaccine administration monitoring programmes in LTC homes that leverage interRAI assessment systems should be widely adopted.

Factors That Predict 1-Year Incident Hip and Non-Hip Fractures for Home Care Recipients: A Linked-Data Retrospective Cohort Study.

OBJECTIVES: The purpose of our study was to identify factors that predict 1-year incident hip and major osteoporotic non-hip fractures (ie, wrist, spine, pelvis, humerus) for home care recipients while accounting for the competing risk of death. DESIGN: We conducted a retrospective cohort study with linked population data. SETTING AND PARTICIPANTS: All home care recipients in Ontario, Canada, receiving services for more than 6 months with an admission assessment between April 1, 2011, and March 31, 2015, were included. METHODS: Clinical data from the Resident Assessment Instrument Home Care were linked to fracture data from the Discharge Abstract Database and the National Acute Care Reporting System. Competing risk proportional hazard regressions using the Fine and Grey method were performed to model the association between potential risk factors and fracture. RESULTS: Previous fall, previous fracture, cognitive impairment, unsteady gait, alcohol use, tobacco use, and Parkinson disease were consistently associated with all fracture types. Cognitive impairment (hazard ratio 2.09; 95% confidence interval 1.86-2.36) and wandering [1.66 (1.06-1.27)] were most predictive of hip fractures and being female [1.86 (1.76-1.98)] and experiencing a previous fracture [1.86 (1.76-1.98)] were most predictive of non-hip fractures. Risk factors unique to non-hip fractures as compared with hip fractures were locomotion ability outdoors and psychotropic medication use. CONCLUSIONS AND IMPLICATIONS: Our results indicate that, in addition to typical fracture risk factors, home care recipients have unique characteristics that increase their risk. Fracture risk assessment tools and subsequent prevention strategies should be modified to accurately identify home care recipients at risk for imminent 1-year fracture.

Development and validation of the fracture risk scale home care (FRS-HC) that predicts one-year incident fracture: an electronic record-linked longitudinal cohort study.

BACKGROUND: Fractures have dire consequences including pain, immobility, and death. People receiving home care are at higher risk for fractures than the general population. Yet, current fracture risk assessment tools require additional testing and assume a 10-year survival rate, when many die within one year. Our objectives were to develop and validate a scale that predicts one-year incident hip fracture using the home care resident assessment instrument (RAI-HC). METHODS: This is a retrospective cohort study of linked population data. People receiving home care in Ontario, Canada between April 1st, 2011 and March 31st, 2015 were included. Clinical data were obtained from the RAI-HC which was linked to the Discharge Abstract Database and National Ambulatory Care Reporting System to capture one-year incident hip fractures. Seventy-five percent (n = 238,011) of the sample were randomly assigned to a derivation and 25% (n = 79,610) to a validation sample. A decision tree was created with the derivation sample using known fracture risk factors. The final nodes of the decision tree were collapsed into 8 risk levels and logistic regression was performed to determine odds of having a fracture for each level. c-Statistics were calculated to compare the discriminative properties of the full, derivation, and validation samples. RESULTS: Approximately 60% of the sample were women and 53% were 80 years and older. A total of 11,526 (3.6%) fractures were captured over the 1-year time period. Of these, 5057 (43.9%) were hip fractures. The proportion who experienced a hip fracture in the next year ranged from 0.3% in the lowest risk level to 5.2% in the highest risk level. People in the highest risk level had 18.8 times higher odds (95% confidence interval, 14.6 to 24.3) of experiencing a hip fracture within one year than those in the lowest. c-Statistics were similar for the full (0.658), derivation (0.662), and validation (0.645) samples. CONCLUSIONS: The FRS-HC predicts hip fracture over one year and should be used to guide clinical care planning for home care recipients at high risk for fracture. Our next steps are to develop a fracture risk clinical assessment protocol to link treatment recommendations with identified fracture risk.

A Canadian Cohort Study to Evaluate the Outcomes Associated with a Multicenter Initiative to Reduce Antipsychotic Use in Long-Term Care Homes.

OBJECTIVES: To evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels. DESIGN: Longitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement's Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories. SETTING AND PARTICIPANTS: Adults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study. MEASURES: Assessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use. INTERVENTION: Quality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis. RESULTS: At the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms. CONCLUSIONS/IMPLICATIONS: The Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care.

One Way Out? A Multistate Transition Model of Outcomes After Nursing Home Admission.

OBJECTIVES: To understand how the odds of both adverse and positive transitions vary over the course of episodes of care in nursing homes. DESIGN: Retrospective cohort study of individuals admitted to nursing homes using clinical and administrative Canadian Resident Assessment Instrument version 2 data linked to emergency department and hospital records. SETTING AND PARTICIPANTS: Adults aged 65 years and older, admitted to nursing homes in Ontario, Alberta, British Columbia, and Yukon Territories in Canada, from 2010 to 2015. The sample involved 163,176 individuals with 1,088,336 RAI 2.0 assessments. MEASURES: Data on mortality and hospitalization were obtained from nursing home and hospital records. Multistate Markov models were employed to estimate odds ratios characterizing covariate effects on transitions to different states of health, hospitalization, and death, stratified by day of stay beginning with the initial 90-day period after admission to a nursing home. RESULTS: The first 90 days of stay after admission were characterized by higher odds of both adverse and positive outcomes after adjusting for numerous covariates. Newly admitted residents had greater odds of becoming worse in health instability, being hospitalized, or dying. However, they also had greater odds of being discharged home or improving in health compared with later stages of the episode of care. These associations varied by the resident's Changes in Health, End-Stage Disease, Signs, and Symptoms (CHESS) scores at the start of each 90-day follow-up period, and CHESS was associated with differential rates of death, hospitalization, and discharge home. CONCLUSIONS/IMPLICATIONS: The initial 90-day period after nursing home placement is one in which the likelihood of both adverse and positive changes is elevated for nursing home residents. Special efforts must be taken after admission to identify and respond to risk factors that may increase the resident's odds of negative outcomes. At the same time, there may be a window of opportunity for the person's transition back to the community after a brief nursing home stay.

Validation of a one year fracture prediction tool for absolute hip fracture risk in long term care residents.

BACKGROUND: Frail older adults living in long term care (LTC) homes have a high fracture risk, which can result in reduced quality of life, pain and death. The Fracture Risk Scale (FRS) was designed for fracture risk assessment in LTC, to optimize targeting of services in those at highest risk. This study aims to examine the construct validity and discriminative properties of the FRS in three Canadian provinces at 1-year follow up. METHODS: LTC residents were included if they were: 1) Adults admitted to LTC homes in Ontario (ON), British Columbia (BC) and Manitoba (MB) Canada; and 2) Received a Resident Assessment Instrument Minimum Data Set Version 2.0. After admission to LTC, one-year hip fracture risk was evaluated for all the included residents using the FRS (an eight-level risk scale, level 8 represents the highest fracture risk). Multiple logistic regressions were used to determine the differences in incident hip or all clinical fractures across the provinces and FRS risk levels. We examined the differences in incident hip or all clinical fracture for each FRS level across the three provinces (adjusted for age, BMI, gender, fallers and previous fractures). We used the C-statistic to assess the discriminative properties of the FRS for each province. RESULTS: Descriptive statistics on the LTC populations in ON (n = 29,848), BC (n = 3129), and MB (n = 2293) are: mean (SD) age 82 (10), 83 (10), and 84 (9), gender (female %) 66, 64, and 70% respectively. The incident hip fractures and all clinical fractures for FRS risk level were similar among the three provinces and ranged from 0.5 to 19.2% and 1 to 19.2% respectively. The overall discriminative properties of the FRS were similar between ON (C-statistic = 0.673), BC (C-statistic = 0.644) and MB (C-statistic = 0.649) samples. CONCLUSION: FRS is a valid tool for identifying LTC residents at different risk levels for hip or all clinical fractures in three provinces. Having a fracture risk assessment tool that is tailored to the LTC context and embedded within the routine clinical assessment may have significant implications for policy, service delivery and care planning, and may improve care for LTC residents across Canada.

Measuring health related quality of life (HRQoL) in community and facility-based care settings with the interRAI assessment instruments: development of a crosswalk to HUI3.

BACKGROUND: Health-related quality of life (HRQoL) measures are of interest because they can be used to describe health of populations and represent a broader health outcome for population health analyses than mortality rates or life expectancy. The most widely used measure of HRQoL for deriving estimates of health-adjusted life expectancy is the Health Utilities Index Mark 3 (HUI3). The HUI3 is available in most national surveys administered by Statistics Canada, and has been used as part of a microsimulation model to examine the impact of neurological conditions over the life course. Persons receiving home care and nursing home services are often not well-represented in these surveys; however, interRAI assessment instruments are now used as part of normal clinical practice in these settings for nine Canadian provinces/territories. Building on previous research that developed a HUI2 crosswalk for the interRAI assessments, the present study examined a new interRAI HRQoL index crosswalked to the HUI3. METHODS: interRAI and survey data were used to examine the distributional properties of global and domain-specific interRAI HRQoL and HUI3 index scores, respectively. Three populations were considered: well-elderly persons not receiving home care, home care clients and nursing home residents. RESULTS: The mean HUI3 and interRAI HRQoL index global scores declined from independent healthy older persons to home care clients, followed by nursing home residents. For the home care and nursing home populations, the interRAI HRQoL global estimates tended to be lower than HUI3 global scores obtained from survey respondents. While there were some statistically significant age, sex and diagnostic group differences in global scores and within attributes, the most notable differences were between populations from different care settings. DISCUSSION: The present study provides strong evidence for the validity of the interRAI HRQoL based on comparisons of distributional properties with those obtained with survey data based on the HUI3. The results demonstrate the importance of admission criteria for home care and nursing home settings, where function plays a more important role than demographic or diagnostic criteria. The interRAI HRQoL has a distinct advantage because it is gathered as part of normal clinical practice in care settings where interRAI instruments are mandatory and are used to assess all eligible persons in those sectors. In particular, those with severe cognitive and functional impairments (who tend to be under-represented in survey data) will be evaluated using the interRAI tools. Future research should build on this work by providing direct, person-level comparisons of interRAI HRQoL index and HUI3 scores, as well as longitudinal analyses to examine responsiveness to change.

Predictors of Electroconvulsive Therapy Use in a Large Inpatient Psychiatry Population.

OBJECTIVE: There is limited research on reliable and clinically useful predictors of electroconvulsive therapy (ECT) use. We aimed to examine factors that predict ECT use in an inpatient psychiatric population. DESIGN: Retrospective analysis of provincial database for inpatient psychiatry. METHODS: This study is a retrospective analysis of a provincial database for inpatient psychiatry. The study includes all psychiatric inpatients 18 years or older in Ontario, Canada, assessed with the Resident Assessment Instrument for Mental Health (RAI-MH) within the first 3 days of admission between 2009 and 2014 (n = 153,023). The RAI-MH is a validated assessment tool which includes a breadth of information on symptoms, self-harm, functioning, social support, comorbid medical diagnoses, and risk appraisal. Multivariable analyses were performed using SAS. RESULTS: One hundred forty-five thousand seven hundred (95.2%) of patients admitted had no history of ECT treatment and were not scheduled to receive ECT. A total of 7323 (or 4.8% of the patient population) had either a history of ECT use or were scheduled to receive ECT. Overall rate of ECT use was highest in patients with a provisional diagnosis of mood disorder (7.2%) compared with schizophrenia/other psychotic disorder (3.1%) or substance-related disorder (1.7%). Women were more likely to receive ECT compared with men (overall rates of ECT use 6.2% and 3.4%, respectively). Overall rate of ECT use increased significantly with increasing age. Number of prior hospitalizations was also a strong predictor of ECT use. Conversely, patients with elevated Risk of Harm to Others, schizophrenia, or a substance use disorder were all significantly less likely to receive ECT. All variables examined were statistically significant (P < 0.0001). Higher Severity of Self Harm Scores predicted past use, but not scheduled use of ECT. CONCLUSIONS: This is the largest study to date on predictors of ECT use. Utilization of RAI-MH is a novel and clinically useful method for evaluating predictors of ECT use. Predictors of ECT use within an inpatient population include: presence of a mood disorder, female sex, older age, low risk of harm to others, number of lifetime hospitalizations, lack of substance use disorder, and inability to care for self.

Development and validation of the Fracture Risk Scale (FRS) that predicts fracture over a 1-year time period in institutionalised frail older people living in Canada: an electronic record-linked longitudinal cohort study.

OBJECTIVES: To develop and validate our Fracture Risk Scale (FRS) over a 1-year time period, using the long-term care (LTC) Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS 2.0). DESIGN: A retrospective cohort study. SETTING: LTC homes in Ontario, Canada. PARTICIPANTS: Older adults who were admitted to LTC and received a RAI-MDS 2.0 admission assessment between 2006 and 2010. RESULTS: A total of 29 848 LTC residents were enrolled in the study. Of these 22 386 were included in the derivation dataset and 7462 individual were included in the validation dataset. Approximately 2/3 of the entire sample were women and 45% were 85 years of age or older. A total of 1553 (5.2%) fractures were reported over the 1-year time period. Of these, 959 (61.8%) were hip fractures. Following a hip fracture, 6.3% of individuals died in the emergency department or as an inpatient admission and did not return to their LTC home. Using decision tree analysis, our final outcome scale had eight risk levels of differentiation. The percentage of individuals with a hip fracture ranged from 0.6% (lowest risk level) to 12.6% (highest risk level). The area under the curve of the outcome scale was similar for the derivation (0.67) and validation (0.69) samples, and the scale exhibited a good level of consistency. CONCLUSIONS: Our FRS predicts hip fracture over a 1-year time period and should be used as an aid to support clinical decisions in the care planning of LTC residents. Future research should focus on the transformation of our scale to a Clinical Assessment Protocol and to assess the FRS in other healthcare settings.

Individuals with neurological diseases are at increased risk of fractures within 180 days of admission to long-term care in Ontario.

BACKGROUND: Individuals residing in long-term care (LTC) are more likely to have a fragility fracture than community-dwelling seniors. The purpose of this study was to determine whether the presence of neurological diseases was associated with an increased risk of fracture within 180 days of admission to LTC. METHODS: This retrospective cohort study used data collected in the LTC setting using the Resident Assessment Instrument (RAI) 2.0 during the period from 2006 to 2011 (N=42,089). Multivariable logistic regression analyses were conducted to determine the associations between the presence of neurological conditions and incident fractures, with and without adjustment for clinical variables. RESULTS: The incident fracture rate for all LTC residents was 2.6% (N=1,094). Neurological condition group size ranged from n=21,015 for Alzheimer's disease or related dementias (ADRD) to n=21 for muscular dystrophy (MD). The incidence of fracture among residents with specific neurological diseases was as follows: ADRD, 3.2% (n=672), MD, 4.8% (n=1), Parkinson's disease, 2.5% (n=57), stroke, 2.3% (n=166), epilepsy, 2.5% (n=38), Huntington's disease, 1.4% (n=1), multiple sclerosis, 0.3% (n=1) and traumatic brain injury, 3.8% (n=11); among the comparison group with no neurological conditions, the fracture rate was 2.0% (n=366). The neurological diseases that were associated with a significantly greater odds of having an incident fracture in the first 180 days of LTC admission were as follows: ADRD (1.3; 95% CI: 1.1-1.5), epilepsy (1.5; 95% CI: 1.0-2.1) and traumatic brain injury (2.7; 95% CI: 1.4-5.0). CONCLUSION: LTC residents with ADRD, epilepsy and traumatic brain injury are at a higher risk for sustaining an incident fracture in the first 180 days of admission and should be considered for fracture prevention strategies.

Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study.

BACKGROUND: Home care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario. METHODS: A retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Abstract Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences. RESULTS: The study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death. CONCLUSIONS: Our study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.

Patterns and determinants of dementia pharmacotherapy in a population-based cohort of home care clients.

BACKGROUND: Little is known about the needs of older home care clients with dementia or their key quality of care issues, including their use of pharmacotherapy for Alzheimer's disease. OBJECTIVES: The objectives of this study were to (1) describe the sociodemographic, psychosocial, and health characteristics of clients with dementia (relative to two control subgroups) from a population-based home care cohort; and, (2) determine the distribution and associated characteristics of cholinesterase inhibitor (ChEI) and/or memantine use among dementia clients overall and according to medication class, comorbid illness, and year of assessment. METHODS: This cross-sectional study included all home care clients aged 50 years or older assessed with the Resident Assessment Instrument-Home Care (RAI-HC) in Ontario, Canada from January 2003 to December 2010. Multivariable logistic regression models were used to identify factors associated with receiving a dementia medication (a ChEI and/or memantine). RESULTS: There were 104,802 (21.5 %) clients with a diagnosis of dementia, 92,529 (18.9 %) cognitively impaired clients without a dementia diagnosis, and 290,929 (59.6 %) cognitively intact clients. Relative to the comparison groups, dementia clients were more likely to have reported conflicts with others, a distressed caregiver, greater levels of cognitive and functional impairment, and to exhibit wandering, aggressive behaviors, anxiety, hallucinations or delusions, and swallowing problems. Approximately half of dementia clients were taking a dementia medication, most commonly donepezil. Characteristics most strongly associated with use of ChEI monotherapy included age greater than 64 (especially 75-84), absence of economic barriers, availability of a primary caregiver, year of assessment, moderate to severe cognitive impairment, relative independence in function, health stability, no depressive symptoms or hallucinations/delusions, no recent hospitalization, use of at least 9 medications, the absence of chronic health and neurological conditions, and the use of an antipsychotic or antidepressant. For combination therapy, strong positive associations were observed for younger age, year of assessment, increasing cognitive impairment, presence of a primary caregiver, male sex, absence of economic barriers, use of at least 9 medications, and various indicators of positive health status (e.g., stability in health, absence of chronic health and neurological conditions, and no recent hospitalization). The percentage of clients receiving ChEIs increased with cognitive impairment scores but declined slightly at the highest level of impairment, whereas the percentage receiving memantine increased with cognitive impairment level. The number and percentage of dementia clients receiving any pharmacotherapy increased during the study interval. CONCLUSIONS: We observed a relatively high prevalence of dementia-specific pharmacotherapy among Ontario long-stay home care clients as well as significant variation in utilization patterns by select sociodemographic, functional, and clinical characteristics, and over time. While physicians generally followed recommended guidelines regarding appropriate dementia pharmacotherapy, continued efforts to monitor practice patterns are required among vulnerable older adults across care settings.

Prevalence and predictors of antibiotic use in community-based elderly in Ontario, Canada.

Little is known about antibiotic use in the elderly receiving home care. We found that 6,873 (5.4%) of 126,339 home care patients in Ontario received antibiotic treatment; 26% of the antibiotics administered were fluoroquinolones. Antibiotic treatment was most frequent in patients less than 65 years of age and among those with a poorer health status.

Identification of safety outcomes for Canadian home care clients: evidence from the resident assessment instrument--home care reporting system concerning emergency room visits.

Problems of patient safety have been well documented in hospitals. However, we have very limited data about patient safety problems among home care clients. The purpose of this study was to assess the burden of safety problems among Canadian home care clients using data collected through the Resident Assessment Instrument - Home Care (RAI HC), and to explore the role of age and patient safety risk factors in explaining variations in adverse outcomes, with a particular focus on emergency room visits. The study methodology involved a secondary analysis of data collected through the Canadian Home Care Reporting System. The study sample consisted of all home care clients who qualified to receive an RAI HC assessment from Ontario, Nova Scotia and Winnipeg Regional Health Authority for the 2003-2007 reporting period. There were a total of 30,396 cases with a paired intake and 12-month follow-up assessment available for analysis. New falls, unintended weight loss, new emergency room (ER) visits and new hospital visits were the most prevalent adverse outcomes. A history of falls, a cancer diagnosis, polypharmacy, receiving an anxiolytic medication and receiving an antidepressant medication were associated with an increased risk of ER visits, while low self reliance and limitation in activities of living were associated with a decreased risk of ER visits. Understanding clients'risk profiles is foundational to effective patient care.

The nature of safety problems among Canadian homecare clients: evidence from the RAI-HC reporting system.

AIM(S): The purpose of this study was to identify the nature of patient safety problems among Canadian homecare (HC) clients, using data collected through the RAI-HC((c)) assessment instrument. BACKGROUND: Problems of patient safety have been well documented in hospitals. However, we have very limited data about patient safety problems among HC clients. METHOD(S): The study methodology involved a secondary analysis of data collected through the Canadian home care reporting system. The study sample consisted of all HC clients who qualified to receive a RAI-HC assessment from Ontario, Nova Scotia and Winnipeg Regional Health Authority for the 2003-2007 reporting period. There were a total of 238 958 cases available for analysis; 205 953 from Ontario, 26 751 from Nova Scotia and 6254 from Winnipeg Regional Health Authority. RESULTS: New fall (11%), unintended weight loss (9%), new emergency room (ER) visits (7%) and new hospital visits (8%) were the most prevalent potential adverse events identified in our study. A small proportion of the HC clients experienced a new urinary tract infection (2%). CONCLUSION(S): Understanding clients' risk profiles is foundational to effective patient care management. IMPLICATIONS FOR NURSING MANAGEMENT: We need to begin to develop evidence about best practices for ameliorating safety risk.

Factors associated with pharmacologic treatment of osteoporosis in an older home care population.

BACKGROUND: A number of studies have shown low rates of osteoporosis treatment. Few, if any, have assessed a comprehensive range of functional and clinical correlates of treatment coverage. Our objective was to examine which sociodemographic, clinical, and functional characteristics are associated with pharmacotherapy for osteoporosis among community-based seniors. METHODS: The study sample included 48,689 home care clients aged >/= 65 years in Ontario, Canada. Treatment coverage (calcium and vitamin D and/or anti-osteoporotic drugs) was assessed in two subgroups, clients with a diagnosis of osteoporosis (without fracture) and those with a prevalent fracture. Sociodemographic, health, and functional measures available from the Resident Assessment Instrument for Home Care (RAI-HC) were assessed as correlates of treatment in multivariable logistic regression analyses. RESULTS: Approximately 59% of clients with a diagnosis of osteoporosis were receiving pharmacotherapy, compared with 27% of those with a prevalent fracture. For both subgroups, treatment coverage was significantly lower among clients with at least three chronic conditions, health instability, fewer than nine medications, functional impairment, and depressive symptoms and among those clients who were widowed. Among clients with a diagnosis of osteoporosis, treatment was positively associated with cognitive impairment and negatively associated with confinement to a wheelchair or bed. Men with a prevalent fracture were significantly less likely to receive treatment, particularly in the absence of an osteoporosis diagnosis. CONCLUSIONS: Many older adults with presumed osteoporosis in our study were not receiving drug therapy for this condition. Indicators of clinical instability and functional decline appear to represent influential factors in treatment decisions. Despite a lower likelihood of treatment among men with a prevalent fracture, this sex difference in treatment largely disappeared in the presence of an osteoporosis diagnosis.

Pain among the oldest old in community and institutional settings.

The relationship between pain and increasing age was investigated using data from two different care settings collected on a province-wide basis in Ontario. Home care clients (HC) and complex continuing care patients (CCC) are assessed using the Resident Assessment Instrument-Home Care and Resident Assessment Instrument 2.0 instruments, respectively, as part of normal clinical practice. For this study, the sample was restricted to those aged 65 years and older and totaled 193,158 individuals. Centenarians (those 100 years of age or older) made up 0.41% (n=788) of the sample. Pain was assessed according to a previously validated pain scale embedded in both assessments that uses items on frequency and intensity. Based on 5-year age groups beginning at 65, the mean reported pain score was lower with each increment in age for men and women. Multiple logistic regression models were constructed and the odds ratios for pain in both HC and CCC groups decreased consistently in higher age groups after adjusting for disease diagnoses, cognition, functional status and health indicators. A model that included categories of analgesic medications coded based on the WHO pain ladder showed the relationship persisted after controlling for analgesia. In clinical settings, the oldest old appear to have lower levels of pain compared with the young old after adjusting for a variety of potential confounding variables.