Weight Loss in Newly Admitted Nursing Home Residents With Obesity.

BACKGROUND: The prevalence of obesity (body mass index ≥ 30) among nursing home residents has been increasing, but there has been little research on weight change in this population. We examined resident characteristics associated with substantial weight loss among nursing home residents with obesity. METHODS: Using data from the Minimum Data Set 3.0, this retrospective study included long-stay nursing home residents with obesity newly admitted to a facility in 2014 who had annual assessments in 2015. Substantial weight loss was defined as a loss of ≥10% body weight within a year. Multivariate regression analyses were conducted to identify factors associated with weight loss, including demographic characteristics, medical conditions, and functional limitations in activities of daily living (ADL). RESULTS: Among 59782 newly admitted nursing home residents with obesity, 23% experienced substantial weight loss during their first year in the nursing home. Moderate ADL dependency (odds ratio [OR] = 1.42, 95% confidence interval [CI]: 1.31-1.53), severe ADL dependency (OR = 1.83; 95% CI: 1.67-1.99), severe mobility impairment (OR = 1.15; 95% CI: 1.04-1.23), and severe cognitive impairment (OR = 1.13; 95% CI: 1.07-1.19), as well as cancer (OR = 1.10; 95% CI: 1.01-1.20), heart failure (OR = 1.06; 95% CI: 1.01-1.11), end-stage renal disease (OR = 1.17; 95% CI: 1.11-1.23), and bowel incontinence (OR = 1.19; 95% CI: 1.14-1.25) were associated with weight loss. CONCLUSION: Substantial weight loss is common among nursing home residents with obesity over a 1-year period following admission, and these residents have a greater burden of functional and cognitive impairment and specific medical conditions. These findings suggest the need to further elucidate the clinical implications of weight loss among this population.

Trends in breast and prostate cancer screening and diagnostic procedures during the COVID-19 pandemic in central Massachusetts.

PURPOSE: We calculated rates of breast and prostate cancer screening and diagnostic procedures performed during the COVID-19 pandemic through December 2021 compared to the same months in 2019 in a large healthcare provider group in central Massachusetts. METHODS: We included active patients of the provider group between January 2019 and December 2021 aged 30-85 years. Monthly rates of screening mammography and digital breast tomosynthesis, breast MRI, total prostate specific antigen (PSA), and breast or prostate biopsy per 1,000 people were compared by year overall, by age, and race/ethnicity. Completed procedures were identified by relevant codes in electronic health record data. RESULTS: Rates of screening mammography, tomosynthesis, and PSA testing reached the lowest levels in April-May 2020. Breast cancer screening rates decreased 43% in March and 99% in April and May 2020, compared to 2019. Breast cancer screening rates increased gradually beginning in June 2020 through 2021, although more slowly in Black and Hispanic women and in women aged 75-85. PSA testing rates decreased 34% in March, 78% in April, and 53% in May 2020, but rebounded to pre-pandemic levels by June 2020; trends were similar across groups defined by age and race/ethnicity. CONCLUSION: The observed decline in two common screening procedures during the COVID-19 pandemic reflects the impact of the pandemic on cancer early detection and signals potential downstream effects on the prognosis of delayed cancer diagnoses. The slower rate of return for breast cancer screening procedures in certain subgroups should be investigated to ensure all women return for routine screenings.

The Association of Nursing Home Characteristics and Quality with Adverse Events After a Hospitalization.

BACKGROUND/OBJECTIVES: We previously found high rates of adverse events (AEs) for long-stay nursing home residents who return to the facility after a hospitalization. Further evidence about the association of AEs with aspects of the facilities and their quality may support quality improvement efforts directed at reducing risk. DESIGN: Prospective cohort analysis. SETTING AND PARTICIPANTS: 32 nursing homes in the New England states. A total of 555 long-stay residents contributed 762 returns from hospitalizations. METHODS: We measured the association between AEs developing in the 45 days following discharge back to long-term care and characteristics of the nursing homes including bed size, ownership, 5-star quality ratings, registered nurse and nursing assistant hours, and the individual Centers for Medicare & Medicaid Services (CMS) quality indicators. We constructed Cox proportional hazards models controlling for individual resident characteristics that were previously found associated with AEs. RESULTS: We found no association of AEs with most nursing home characteristics, including 5-star quality ratings and the composite quality score. Associations with individual quality indicators were inconsistent and frequently not monotonic. Several individual quality indicators were associated with AEs; the highest tertile of percentage of residents with depression (4%-25%) had a hazard ratio (HR) of 1.65 [95% confidence interval (CI) 1.16, 2.35] and the highest tertile of the percentage taking antipsychotic medications (18%-35%) had an HR of 1.58 (CI 1.13, 2.21). The percentage of residents needing increased assistance with activities of daily living was statistically significant but not monotonic; the middle tertile (13% to <20%) had an HR of 1.69 (CI 1.16, 2.47). CONCLUSIONS AND IMPLICATIONS: AEs occurring during transitions between nursing homes and hospitals are not explained by the characteristics of the facilities or summary quality scores. Development of risk reduction approaches requires assessment of processes and quality beyond the current quality measures.

Effect of a Multifaceted Clinical Pharmacist Intervention on Medication Safety After Hospitalization in Persons Prescribed High-risk Medications: A Randomized Clinical Trial.

Importance: The National Action Plan for Adverse Drug Event (ADE) Prevention identified 3 high-priority, high-risk drug classes as targets for reducing the risk of drug-related injuries: anticoagulants, diabetes agents, and opioids. Objective: To determine whether a multifaceted clinical pharmacist intervention improves medication safety for patients who are discharged from the hospital and prescribed medications within 1 or more of these high-risk drug classes. Design, Setting, and Participants: This randomized clinical trial was conducted at a large multidisciplinary group practice in Massachusetts and included patients 50 years or older who were discharged from the hospital and prescribed at least 1 high-risk medication. Participants were enrolled into the trial from June 2016 through September 2018. Interventions: The pharmacist-directed intervention included an in-home assessment by a clinical pharmacist, evidence-based educational resources, communication with the primary care team, and telephone follow-up. Participants in the control group were provided educational materials via mail. Main Outcomes and Measures: The study assessed 2 outcomes over a 45-day posthospital discharge period: (1) adverse drug-related incidents and (2) a subset defined as clinically important medication errors, which included preventable or ameliorable ADEs and potential ADEs (ie, medication-related errors that may not yet have caused injury to a patient, but have the potential to cause future harm if not addressed). Clinically important medication errors were the primary study outcome. Results: There were 361 participants (mean [SD] age, 68.7 [9.3] years; 177 women [49.0%]; 319 White [88.4%] and 8 Black individuals [2.2%]). Of these, 180 (49.9%) were randomly assigned to the intervention group and 181 (50.1%) to the control group. Among all participants, 100 (27.7%) experienced 1 or more adverse drug-related incidents, and 65 (18%) experienced 1 or more clinically important medication errors. There were 81 adverse drug-related incidents identified in the intervention group and 72 in the control group. There were 44 clinically important medication errors in the intervention group and 45 in the control group. The intervention did not significantly alter the per-patient rate of adverse drug-related incidents (unadjusted incidence rate ratio, 1.13; 95% CI, 0.83-1.56) or clinically important medication errors (unadjusted incidence rate ratio, 0.99; 95% CI, 0.65-1.49). Conclusions and Relevance: In this randomized clinical trial, there was not an observed lower rate of adverse drug-related incidents or clinically important medication errors during the posthospitalization period that was associated with a clinical pharmacist intervention. However, there were study recruitment challenges and lower than expected numbers of events among the study population. Trial Registration: ClinicalTrials.gov Identifier: NCT02781662.

Characteristics of Long-Term Care Residents That Predict Adverse Events after Hospitalization.

BACKGROUND/OBJECTIVES: Adverse events (AEs) occur frequently in long-term care (LTC) residents transitioning from the hospital back to an LTC facility. Measuring the association between resident characteristics and AEs can inform AE risk reduction strategies. DESIGN: Prospective cohort analysis. SETTING: A total of 32 nursing homes from six New England states. PARTICIPANTS: A total of 555 LTC residents contributing 762 transitions from the hospital back to LTC. MEASUREMENTS: We measured the association between all AEs and preventable AEs developing in the 45 days following discharge back to LTC and demographic variables, hospital length of stay (LOS), Charlson Comorbidity Index (CCI) (0-1, 2-3, 4-5 and ≥6), dependency in activities of daily living (ADLs) using the Minimum Data Set Long Form Scale (in quintiles 0-12, 13-15, 16, 17-18, and ≥19), and number of regularly scheduled medications (0-9, 10-13, 14-17, and ≥18). To understand the independent association of each resident characteristic with AEs and preventable AEs, we constructed multiple Cox proportional hazards models. RESULTS: There were 283 discharges with one or more AEs and 212 with preventable AEs. Characteristics independently associated with higher risk of an AE included hospital LOS 9 or more days (hazard ratio [HR] = 1.49; 95% confidence interval [CI] = 1.02-2.17); CCI of 4 to 5 (HR = 1.74; 95% CI = 1.13-2.67) or 6 or higher (HR = 1.58; 95% CI = 1.01-2.46); 18 or more regularly scheduled medications (HR = 1.53; 95% CI = 1.07-2.18); and 19 and above on ADL dependency (HR = 1.78; 95% CI = 1.21-2.62). Results from models with preventable AEs were similar to those with all AEs. CONCLUSION: Increased LOS, higher comorbidity burden, greater dependency in ADLs, and polypharmacy were the resident characteristics most strongly associated with risk of AEs and preventable AEs. We recommend heightened vigilance in the care of LTC residents with these characteristics transitioning back to LTC. We also recommend research to assess strategies to reduce the risk of AEs.

Recruitment Challenges for Low-Risk Health System Intervention Trials in Older Adults: A Case Study.

OBJECTIVE: To assess factors associated with trial participation in the context of a low-risk intervention intended to reduce adverse drug events in recently hospitalized older adults. DESIGN: Mixed methods: analysis of data collected during enrollment efforts and focus groups. SETTING: A large, multispecialty group practice. PARTICIPANTS: Individuals 50 years and older, recently discharged from the hospital and prescribed at least one high-risk medication, were eligible for the trial. Enrollees, decliners, and their caregivers were eligible to participate in focus groups. MEASUREMENTS: Reasons for declining to participate during the initial invitation as well as reasons for not providing consent were recorded. Focus groups were conducted with eligible individuals to explore reasons for enrolling or declining. We conducted multivariable logistic regression to compare characteristics (including sex, age, healthcare proxy, number and type of medications, visiting nurse services, reason for admission, and length of hospital stay) of those who enrolled with those who did not enroll. RESULTS: Of 3,606 individuals determined eligible, 3,147 (87%) declined, 98 (3%) verbally consented to participate but did not complete written consent, and 361 (10%) provided written consent and were considered enrolled. Individuals 80 year and older (odds ratio (OR) = 0.44; 95% confidence interval (CI) = 0.30-0.65) and those with visiting nurse services (OR = 0.64; 95% CI = 0.48-0.85) were least likely to enroll. Among those who provided a reason for declining (2,473), the most common was the belief they did not need additional medication assistance (18%). Another 332 (11%) declined because they were receiving visiting nurse services. CONCLUSION: Recruiting older adults recently discharged from the hospital to participate in trials of low-risk, system-level interventions is challenging and may underenroll the oldest individuals and those potentially at the highest risk for adverse events, limiting generalizability of study findings. Alternative study designs may be more effective than individually randomized trials in assessing low-risk, system-level interventions.

Adverse Events in Long-term Care Residents Transitioning From Hospital Back to Nursing Home.

IMPORTANCE: Transition from hospital to nursing home is a high-risk period for adverse events in long-term care (LTC) residents. Adverse events include harms from medical care, including failure to provide appropriate care. OBJECTIVE: To report the incidence, type, severity, and preventability of adverse events in LTC residents transitioning from hospital back to the same LTC facility. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of LTC residents discharged from hospital back to LTC from March 1, 2016, to December 31, 2017, and followed up for 45 days. In a random sample of 32 nursing homes located in 6 New England states, 555 LTC residents were selected, contributing 762 transitions from hospital back to the same LTC facility. MAIN OUTCOMES AND MEASURES: The main outcome was an adverse event within the 45-day period after transition from hospital back to nursing home. Trained nurse abstractors reviewed nursing home records for the period, and then 2 physicians independently reviewed each potential adverse event to determine whether harm occurred and to characterize the type, severity, and preventability of each event. When reviewers disagreed, they met to reach consensus. RESULTS: Of the 555 individual residents, 365 (65.6%) were female, and the mean (SD) age at the time of discharge was 82.2 (11.5) years. Five hundred twenty (93.7%) were non-Hispanic white, 21 (3.8%) were non-Hispanic black, 9 (1.6%) were Hispanic, and 5 (0.9%) were of other non-Hispanic race/ethnicity. In the cohort, there were 379 adverse events among 762 discharges. One hundred ninety-seven events (52.0%) related to resident care, with pressure ulcers, skin tears, and falls with injury representing the most common types of events in this category. Health care-acquired infections (108 [28.5%]) and adverse drug events (64 [16.9%]) were the next most common. One hundred ninety-eight (52.2%) adverse events were characterized as less serious. However, 145 (38.3%) events were deemed serious, 28 (7.4%) life-threatening, and 8 (2.1%) fatal. In terms of preventability, 267 (70.4%) adverse events were found to be preventable or ameliorable, with less serious events more often considered preventable or ameliorable (146 [73.7%]) compared with more severe events (121 [66.9%]). In addition, resident care-related adverse events such as fall with injury, skin tear, and pressure ulcer were more commonly deemed preventable (173 of 197 [87.8%]) compared with adverse drug events (39 of 64 [60.9%]) or health care-acquired infections (49 of 108 [45.4%]). CONCLUSIONS AND RELEVANCE: Adverse events developed in nearly 4 of 10 of discharges from hospital back to LTC. Most were preventable or ameliorable. Standardized reporting of events and better coordination and information transfer across settings are potential ways to prevent adverse events in LTC residents.

Use of Electronic Health Record Access and Audit Logs to Identify Physician Actions Following Noninterruptive Alert Opening: Descriptive Study.

BACKGROUND: Electronic health record (EHR) access and audit logs record behaviors of providers as they navigate the EHR. These data can be used to better understand provider responses to EHR-based clinical decision support (CDS), shedding light on whether and why CDS is effective. OBJECTIVE: This study aimed to determine the feasibility of using EHR access and audit logs to track primary care physicians' (PCPs') opening of and response to noninterruptive alerts delivered to EHR InBaskets. METHODS: We conducted a descriptive study to assess the use of EHR log data to track provider behavior. We analyzed data recorded following opening of 799 noninterruptive alerts sent to 75 PCPs' InBaskets through a prior randomized controlled trial. Three types of alerts highlighted new medication concerns for older patients' posthospital discharge: information only (n=593), medication recommendations (n=37), and test recommendations (n=169). We sought log data to identify the person opening the alert and the timing and type of PCPs' follow-up EHR actions (immediate vs by the end of the following day). We performed multivariate analyses examining associations between alert type, patient characteristics, provider characteristics, and contextual factors and likelihood of immediate or subsequent PCP action (general, medication-specific, or laboratory-specific actions). We describe challenges and strategies for log data use. RESULTS: We successfully identified the required data in EHR access and audit logs. More than three-quarters of alerts (78.5%, 627/799) were opened by the PCP to whom they were directed, allowing us to assess immediate PCP action; of these, 208 alerts were followed by immediate action. Expanding on our analyses to include alerts opened by staff or covering physicians, we found that an additional 330 of the 799 alerts demonstrated PCP action by the end of the following day. The remaining 261 alerts showed no PCP action. Compared to information-only alerts, the odds ratio (OR) of immediate action was 4.03 (95% CI 1.67-9.72) for medication-recommendation and 2.14 (95% CI 1.38-3.32) for test-recommendation alerts. Compared to information-only alerts, ORs of medication-specific action by end of the following day were significantly greater for medication recommendations (5.59; 95% CI 2.42-12.94) and test recommendations (1.71; 95% CI 1.09-2.68). We found a similar pattern for OR of laboratory-specific action. We encountered 2 main challenges: (1) Capturing a historical snapshot of EHR status (number of InBasket messages at time of alert delivery) required incorporation of data generated many months prior with longitudinal follow-up. (2) Accurately interpreting data elements required iterative work by a physician/data manager team taking action within the EHR and then examining audit logs to identify corresponding documentation. CONCLUSIONS: EHR log data could inform future efforts and provide valuable information during development and refinement of CDS interventions. To address challenges, use of these data should be planned before implementing an EHR-based study.

The Increasing Prevalence of Obesity in Residents of U.S. Nursing Homes: 2005-2015.

BACKGROUND: Obesity prevalence has been increasing over decades among the U.S. population. This study analyzed trends in obesity prevalence among long-stay nursing home residents from 2005 to 2015. METHODS: Data came from the Minimum Data Sets (2005-2015). The study population was limited to long-stay residents (ie, those residing in a nursing home ≥100 days in a year). Residents were stratified into body mass index (BMI)-based groups: underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30); residents with obesity were further categorized as having Class I (30 ≤ BMI < 35), Class II (35 ≤ BMI < 40), or Class III (BMI ≥ 40) obesity. Minimum Data Sets assessments for 2015 were used to compare clinical and functional characteristics across these groups. RESULTS: Obesity prevalence increased from 22.4% in 2005 to 28.0% in 2015. The prevalence of Class III obesity increased from 4.0% to 6.2%. The prevalence of underweight, normal weight, and overweight decreased from 8.5% to 7.2%, from 40.3% to 37.1%, and from 28.9% to 27.8%, respectively. In 2015, compared with residents with normal weight, residents with obesity were younger, were less likely to be cognitively impaired, had high levels of mobility impairment, and were more likely to have important medical morbidities. CONCLUSIONS AND RELEVANCE: There was a steady upward trend in obesity prevalence among nursing home residents for 2005-2015. Medical and functional characteristics of these residents may affect the type and level of care required, putting financial and staffing pressure on nursing homes.

Primary Care Providers' Opening of Time-Sensitive Alerts Sent to Commercial Electronic Health Record InBaskets.

BACKGROUND: Time-sensitive alerts are among the many types of clinical notifications delivered to physicians' secure InBaskets within commercial electronic health records (EHRs). A delayed alert review can impact patient safety and compromise care. OBJECTIVE: To characterize factors associated with opening of non-interruptive time-sensitive alerts delivered into primary care provider (PCP) InBaskets. DESIGN AND PARTICIPANTS: We analyzed data for 799 automated alerts. Alerts highlighted actionable medication concerns for older patients post-hospital discharge (2010-2011). These were study-generated alerts sent 3 days post-discharge to InBaskets for 75 PCPs across a multisite healthcare system, and represent a subset of all urgent InBasket notifications. MAIN MEASURES: Using EHR access and audit logs to track alert opening, we performed bivariate and multivariate analyses calculating associations between patient characteristics, provider characteristics, contextual factors at the time of alert delivery (number of InBasket notifications, weekday), and alert opening within 24 h. KEY RESULTS: At the time of alert delivery, the PCPs had a median of 69 InBasket notifications and had received a median of 379.8 notifications (IQR 295.0, 492.0) over the prior 7 days. Of the 799 alerts, 47.1% were opened within 24 h. Patients with longer hospital stays (>4 days) were marginally more likely to have alerts opened (OR 1.48 [95% CI 1.00-2.19]). Alerts delivered to PCPs whose InBaskets had a higher number of notifications at the time of alert delivery were significantly less likely to be opened within 24 h (top quartile >157 notifications: OR 0.34 [95% CI 0.18-0.61]; reference bottom quartile ≤42). Alerts delivered on Saturdays were also less likely to be opened within 24 h (OR 0.18 [CI 0.08-0.39]). CONCLUSIONS: The number of total InBasket notifications and weekend delivery may impact the opening of time-sensitive EHR alerts. Further study is needed to support safe and effective approaches to care team management of InBasket notifications.

Training in the Conduct of Population-Based Multi-Site and Multi-Disciplinary Studies: the Cancer Research Network's Scholars Program.

Expanding research capacity of large research networks within health care delivery systems requires strategically training both embedded and external investigators in necessary skills for this purpose. Researchers new to these settings frequently lack the skills and specialized knowledge conducive to multi-site and multi-disciplinary research set in delivery systems. This report describes the goals and components of the Cancer Research Network (CRN) Scholars Program, a 26-month training program developed to increase the capacity for cancer research conducted within the network's participating sites, its progression from training embedded investigators to a mix of internal and external investigators, and the content evolution of the training program. The CRN Scholars program was launched in 2007 to assist junior investigators from member sites develop independent and sustainable research programs within the CRN. Resulting from CRN's increased emphasis on promoting external collaborations, the 2013 Scholars program began recruiting junior investigators from external institutions committed to conducting delivery system science. Based on involvement of this broader population and feedback from prior Scholar cohorts, the program has honed its focus on specific opportunities and issues encountered in conducting cancer research within health care delivery systems. Efficiency and effectiveness of working within networks is accelerated by strategic and mentored navigation of these networks. Investing in training programs specific to these settings provides the opportunity to improve multi-disciplinary and multi-institutional collaboration, particularly for early-stage investigators. Aspects of the CRN Scholars Program may help inform others considering developing similar programs to expand delivery system research or within large, multi-disciplinary research networks.

Informed Family Member Involvement to Improve the Quality of Dementia Care in Nursing Homes.

OBJECTIVES: To describe the extent to which nursing homes engaged families in antipsychotic initiation decisions in the year before surveyor guidance revisions were implemented. DESIGN: Mixed-methods study based on semistructured interviews. SETTING: U.S. nursing homes (N = 20) from five CMS regions (III, IV, VI, VIII, IX). PARTICIPANTS: Family members of nursing home residents (N = 41). MEASUREMENTS: Family member responses to closed- and open-ended questions regarding involvement in resident care and antipsychotic initiation. Two researchers used a content analytical approach to code open responses to themes of family involvement in behavior management, decision-making, knowledge of risks and benefits, and informed consent. RESULTS: Fifty-four percent of family members felt highly involved in decisions about behavior management. Forty-two percent recalled being asked how to manage resident behavior without medication, and 17% recalled receipt of information about antipsychotic risks and benefits. Sixty-six percent felt highly involved in the process of initiating antipsychotic medication; 24% reported being asked for input into the antipsychotic initiation decision and knowing before the antipsychotic was started. CONCLUSION: Under existing federal regulations but before guidance revisions were implemented in 2013, more than 40% of families reported being involved in nonpharmacological behavior management of family members, but fewer than one in four reported being involved throughout the entire antipsychotic prescribing process. Interventions that standardize family engagement and promote adherence to existing federal regulations are needed. This discussion builds on these findings to weigh the policy options of greater enforcement of existing regulations versus enactment of new legislation to address this challenging issue.

Harms of cervical cancer screening in the United States and the Netherlands.

We studied harms related to cervical cancer screening and management of screen-positive women in the United States (US) and the Netherlands. We utilized data from four US integrated health care systems (SEARCH), the US National Health Interview Survey, New Mexico state, the Netherlands national histopathology registry, and included studies on adverse health effects of cervical screening. We compared the number of Papanicolaou (Pap) smear tests, abnormal test results, punch biopsies, treatments, health problems (anxiety, pain, bleeding and discharge) and preterm births associated with excisional treatments. Results were age-standardized to the 2007 US population. Based on SEARCH, an estimated 36 million Pap tests were performed in 2007 for 91 million US women aged 21-65 years, leading to 2.3 million abnormal Pap tests, 1.5 million punch biopsies, 0.3 million treatments for precancerous lesions, 5 thousand preterm births and over 8 million health problems. Under the Netherlands screening practice, fewer Pap tests (58%), abnormal test results (64%), punch biopsies (75%), treatment procedures (40%), preterm births (60%) and health problems (63%) would have occurred. The SEARCH data did not differ much from other US data for 2007 or from more recent data up to 2013. Thus compared to the less intensive screening practice in the Netherlands, US practice of cervical cancer screening may have resulted in two- to threefold higher harms, while the effects on cervical cancer incidence and mortality are similar. The results are also of high relevance in making recommendations for HPV screening. Systematic collection of harms data is needed for monitoring and for better incorporation of harms in making screening recommendations.

Use of Indwelling Urinary Catheters in Nursing Homes: Implications for Quality Improvement Efforts.

OBJECTIVES: To describe the epidemiology of indwelling urinary catheter use in nursing homes (NHs). DESIGN: Observational cohort study. SETTING: A purposeful sampling strategy was used to identify a diverse sample of 28 Connecticut NHs, defined in terms of ownership, quality ratings, and bed size. PARTICIPANTS: Long-stay (>100 days) residents of study NHs with an indwelling urinary catheter present at any time over a 1-year period. MEASUREMENTS: Duration of catheter use was determined, and indications for catheter placement were documented. Indications considered appropriate included urinary retention or outlet obstruction, pressure ulcer (Stage 3 or 4 with risk of contamination by urine), hospice care, and need for accurate measurement of input and output. During quarterly follow-up assessments, whether the catheter was still in place or had been removed for any reason other than routine maintenance was determined. RESULTS: The overall rate of any urinary catheter use per 100 resident-beds over a 1-year period was 4.8 (range 1.0-9.9, median 5.1). Of the 228 residents meeting eligibility criteria, a documented indication for the catheter was present in the NH record for 195 (86%). Of those with a documented indication, 99% (n = 193) had one or more indications deemed appropriate, including urinary retention (83%), pressure ulcer (21%), hospice care (10%), and need for accurate measurement of input and output (6%). The urinary catheter was removed at some point during the period of observation in 49% (n = 111) of participants; those with a shorter duration of catheter use before study enrollment were more likely to have the catheter removed during the follow-up period. Of the 111 residents who had the catheter removed, 58 (52.3%) had it reinserted at some point during follow-up. CONCLUSION: These findings suggest that indwelling urinary catheter use in long-stay NH residents is uncommon and generally appropriate and that efforts to improve catheter care and outcomes should extend beyond a singular focus on reducing use.

A Pilot Health Information Technology-Based Effort to Increase the Quality of Transitions From Skilled Nursing Facility to Home: Compelling Evidence of High Rate of Adverse Outcomes.

OBJECTIVES: Older adults are often transferred from hospitals to skilled nursing facilities (SNFs) for post-acute care. Patients may be at risk for adverse outcomes after SNF discharges, but little research has focused on this period. DESIGN: Assessment of the feasibility of a transitional care intervention based on a combination of manual information transmission and health information technology to provide automated alert messages to primary care physicians and staff; pre-post analysis to assess potential impact. SETTING: A multispecialty group practice. PARTICIPANTS: Adults aged 65 and older, discharged from SNFs to home; comparison group drawn from SNF discharges during the previous 1.5 years, matched on facility, patient age, and sex. MEASUREMENTS: For the pre-post analysis, we tracked rehospitalization within 30 days after discharge and adverse drug events within 45 days. RESULTS: The intervention was developed and implemented with manual transmission of information between 8 SNFs and the group practice followed by entry into the electronic health record. The process required a 5-day delay during which a large portion of the adverse events occurred. Over a 1-year period, automated alert messages were delivered to physicians and staff for the 313 eligible patients discharged from the 8 SNFs to home. We compared outcomes to those of individually matched discharges from the previous 1.5 years and found similar percentages with 30-day rehospitalizations (31% vs 30%, adjusted HR 1.06, 95% CI 0.80-1.4). Within the adverse drug event (ADE) study, 30% of the discharges during the intervention period and 30% of matched discharges had ADEs within 45 days. CONCLUSION: Older adults discharged from SNFs are at high risk of adverse outcomes immediately following discharge. Simply providing alerts to outpatient physicians, especially if delivered multiple days after discharge, is unlikely to have any impact on reducing these rates.

Dissemination of Evidence-Based Antipsychotic Prescribing Guidelines to Nursing Homes: A Cluster Randomized Trial.

OBJECTIVES: To evaluate the effectiveness of efforts to translate and disseminate evidence-based guidelines about atypical antipsychotic use to nursing homes (NHs). DESIGN: Three-arm, cluster randomized trial. SETTING: NHs. PARTICIPANTS: NHs in the state of Connecticut. MEASUREMENTS: Evidence-based guidelines for atypical antipsychotic prescribing were translated into a toolkit targeting NH stakeholders, and 42 NHs were recruited and randomized to one of three toolkit dissemination strategies: mailed toolkit delivery (minimal intensity); mailed toolkit delivery with quarterly audit and feedback reports about facility-level antipsychotic prescribing (moderate intensity); and in-person toolkit delivery with academic detailing, on-site behavioral management training, and quarterly audit and feedback reports (high intensity). Outcomes were evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. RESULTS: Toolkit awareness of 30% (7/23) of leadership of low-intensity NHs, 54% (19/35) of moderate-intensity NHs, and 82% (18/22) of high-intensity NHs reflected adoption and implementation of the intervention. Highest levels of use and knowledge among direct care staff were reported in high-intensity NHs. Antipsychotic prescribing levels declined during the study period, but there were no statistically significant differences between study arms or from secular trends. CONCLUSION: RE-AIM indicators suggest some success in disseminating the toolkit and differences in reach, adoption, and implementation according to dissemination strategy but no measurable effect on antipsychotic prescribing trends. Further dissemination to external stakeholders such as psychiatry consultants and hospitals may be needed to influence antipsychotic prescribing for NH residents.

Cervical cancer screening and follow-up in 4 geographically diverse US health care systems, 1998 through 2007.

BACKGROUND: Cervical cancer screening and follow-up guidelines have changed considerably in recent years, but to the authors' knowledge few published reports exist to estimate the impact of these changes in community-based settings. The authors examined the patterns and results of cervical cancer testing and follow-up over a decade in 4 geographically diverse US health care systems to inform the future evaluation of changes resulting from increased uptake of the human papillomavirus (HPV) vaccination. METHODS: The authors studied women aged 21 to 65 years who were members of one of these health systems at any time between 1998 and 2007. Data were collected and standardized across sites, based on receipt of Papanicolaou (Pap) and HPV tests, HPV vaccination, cervical biopsies, and treatment of cervical dysplasia. Annual rates (per 1000 person-years) of Pap testing, HPV testing, and cervical biopsy and treatment procedures were calculated. Screening intervals and trends in the results of screening Pap tests and cervical biopsies also were examined. RESULTS: Pap testing rates decreased (from 483 per 1000 person-years in 2000 to 412 per 1000 person-years in 2007) and HPV testing rates increased over the study period. Screening frequency varied across health care systems, and many women continued to receive annual testing. All 4 sites moved to less frequent screening over the study period without marked changes in the overall use of cervical biopsy or treatment. CONCLUSIONS: Despite differences over time and across health plans in rates of cervical cancer testing and follow-up cervical procedures, the authors found no notable differences in Pap test results, diagnostic or treatment procedure rates, or pathological outcomes. This finding suggests that the longer screening intervals did not lead to more procedures or more cancer diagnoses.

Rationales that providers and family members cited for the use of antipsychotic medications in nursing home residents with dementia.

OBJECTIVES: To describe the rationales that providers and family members cite for the use of antipsychotic medications in people with dementia living in nursing homes (NHs). DESIGN: Qualitative, descriptive study. SETTING: Twenty-six medium-sized and large facilities in five Centers for Medicare and Medicaid Services regions. PARTICIPANTS: Individuals diagnosed with dementia who received an antipsychotic medication. MEASUREMENTS: Data were collected from medical record abstraction and interviews with prescribers, administrators, direct care providers, and family members. Textual data from medical record abstraction and responses to open-ended interview questions were analyzed using directed content analysis techniques. A coding scheme was developed, and coded reasons for antipsychotic prescribing were summarized across all sources. RESULTS: Major categories of reasons for use of antipsychotic medications in the 204 NH residents in the study sample were behavioral (n = 171), psychiatric (n = 159), emotional states (n = 105), and cognitive diagnoses or symptoms (n = 114). The most common behavioral reasons identified were verbal (n = 91) and physical (n = 85) aggression. For the psychiatric category, psychosis (n = 95) was most frequently described. Anger (n = 93) and sadness (n = 20) were the most common emotional states cited. CONCLUSION: The rationale for use of antipsychotic drug therapy frequently relates to a wide variety of indications for which these drugs are not approved and for which evidence of efficacy is lacking. These findings have implications for clinical practice and policy.

Use of atypical antipsychotics in nursing homes and pharmaceutical marketing.

OBJECTIVES: To describe the current extent and type of pharmaceutical marketing in nursing homes (NHs) in one state and to provide preliminary evidence for the potential influence of pharmaceutical marketing on the use of atypical antipsychotics in NHs. DESIGN: Nested mixed-methods, cross-sectional study of NHs in a cluster randomized trial. SETTING: Forty-one NHs in Connecticut. PARTICIPANTS: NH administrators, directors of nursing, and medical directors (n = 93, response rate 75.6%). MEASUREMENTS: Quantitative data, including prescription drug dispensing data (September 2009-August 2010) linked with Nursing Home Compare data (April 2011), were used to determine facility-level prevalence of atypical antipsychotic use, facility-level characteristics, NH staffing, and NH quality. Qualitative data, including semistructured interviews and surveys of NH leaders conducted in the first quarter of 2011, were used to determine encounters with pharmaceutical marketing. RESULTS: Leadership at 46.3% of NHs (n = 19) reported pharmaceutical marketing encounters, consisting of educational training, written and Internet-based materials, and sponsored training. No association was detected between level of atypical antipsychotic prescribing and reports of any pharmaceutical marketing by at least one NH leader. CONCLUSION: NH leaders frequently encounter pharmaceutical marketing through a variety of ways, although the impact on atypical antipsychotic prescribing is unclear.

Follow-up and clinical significance of unsatisfactory liquid-based Papanicolaou tests.

BACKGROUND: To the authors' knowledge, few studies to date have examined adherence to recommended guidelines for follow-up and outcomes after an unsatisfactory Papanicolaou (Pap) test (UPT) with liquid-based technologies. METHODS: Within 4 US health plans, the median time to follow-up and the percentage of patients with follow-up testing by 120 days was calculated after a UPT. Multivariable analyses evaluated the association between clinical factors and follow-up testing. The authors compared the risk of a diagnosis of cervical intraepithelial neoplasia of type 2 or worse (CIN2+) after a UPT with the risk after a satisfactory Pap test while controlling for study site, test year, and other covariates. RESULTS: A total of 634,644 Pap tests performed between 2004 and 2010 were included in the current study. Of 1442 UPTs, 53.4% had follow-up testing within 120 days; follow-up differed across the health plans (P<.001) and was found to be higher among patients aged <50 years (57.2% vs 48.8%; P = .01) and those with positive human papillomavirus (HPV) results (84.6% vs 53.9; P <.01). The risk of CIN2+ was similar for patients with both unsatisfactory and satisfactory Pap tests. However, after a UPT, the variables of age <50 years, having no previous history of Pap testing, having a history of a previous abnormal Pap test, and positive HPV status were all found to be risk factors for CIN2+; a positive HPV test was found to be the strongest risk factor for developing CIN2+. A negative HPV test result was protective for a CIN2+ diagnosis. CONCLUSIONS: Various clinical factors associated with the risk of CIN2+ appear to influence the receipt of follow-up after a UPT. HPV test results in patients with UPTs might be used in follow-up strategies; specifically, a negative test result might reduce the urgency for repeat Pap testing.