Designing More Effective Cigar Warnings: An Experiment Among Adult Cigar Smokers.

INTRODUCTION: Little systematic evidence exists about the effectiveness of cigar warnings. This study examined the perceived message effectiveness (PME) of warning statements about different health consequences caused by cigars. PME is a validated self-report scale of how effectively a health message discourages smoking. AIMS AND METHODS: We conducted an online study from April to May 2020 with adults in the United States who used cigars in the past 30 days (n = 777). Participants were randomly assigned to view and rate PME (three items, range 1-5) for seven out of 37 text warning statements about different health consequences from cigar use. Linear mixed effects models evaluated the most effective warning characteristics (eg, type of health consequence), controlling for repeated measures and participant demographics. RESULTS: Analyses showed that health consequences about the cardiovascular system (B = 0.38), mouth (B = 0.40), other digestive (B = 0.45), respiratory system (B = 0.36), and early death (B = 0.36) were associated with higher PME scores than reproductive health consequences (all p values <.001). Similar results were found for these health consequences compared with addiction (all p values p < .001). We also observed that awareness of the health consequence was associated with higher PME scores (B = 0.19, p < .001) and length of the warning message (number of characters) was associated with lower PME scores (B = -0.007, p = .03). No differences were observed between cancer and noncancer health consequences (p = .27) or health consequences that used plain language versus medical jargon (p = .94). CONCLUSIONS: Our study provides new evidence about the perceived effectiveness of different cigar health warning statements and identifies features that may strengthen statements. IMPLICATIONS: Our study with cigar smokers from across the United States provides much-needed evidence concerning the perceived effectiveness of different cigar health warning statements and features that may strengthen such statements. Mandated cigar warnings in the United States could be strengthened by including health consequences that were perceived as more effective in our study (eg, early death), using health consequences that participants were aware of, and using short warning statements.

Developing a toolkit to improve resident and family engagement in the safety of assisted living: Engage-A stakeholder-engaged research protocol.

Assisted living (AL) communities are experiencing rising levels of resident acuity, challenging efforts to balance person-centered care-which prioritizes personhood, autonomy, and relationship-based care practices-with efforts to keep residents safe. Safety is a broad-scale problem in AL that encompasses care concerns (e.g., abuse/neglect, medication errors, inadequate staffing, and infection management) as well as resident issues (e.g., falls, elopement, and medical emergencies). Person and family engagement (PFE) is one approach to achieving a balance between person-centered care and safety. In other settings, PFE interventions have improved patient care processes, outcomes, and experiences. In this paper, we describe the protocol for a multiple methods AHRQ-funded study (Engage) to develop a toolkit for increasing resident and family engagement in AL safety. The study aims are to engage AL residents and family caregivers, AL staff, and other AL stakeholders to (1) identify common AL safety problems; (2) prioritize safety problems and identify and evaluate existing PFE interventions with the potential to address safety problems in the AL setting; and (3) develop a testable toolkit to improve PFE in AL safety. We discuss our methods, including qualitative interviews, a scoping review of existing PFE interventions, and stakeholder panel meetings that involved a Delphi priority-setting exercise. In addition to describing the protocol, we detail how we modified the protocol to address the unique challenges of the COVID-19 pandemic. Study findings will result in a toolkit to improve resident and family engagement in the safety of AL that will be tested in future research.

The Pharmacogenetics of Opiates and Its Impact on Delirium in Mechanically Ventilated Adults: A Pilot Study.

Background: Pharmacogenetics may explain a substantial proportion of the variation seen in the efficacy and risk profile of analgesosedative drugs and the incidence of delirium in critically ill adults. Objectives: Conduct a feasibility study to demonstrate the reliability of collecting and analyzing pharmacogenetic information from critically ill patients and to assess the impact of pharmacogenetics on intensive care unit (ICU) outcomes. Methods: We prospectively enrolled subjects from the Medical ICU at the University of North Carolina (UNC). DNA was obtained via a buccal swab and evaluated using the DNA2Rx assay. We collected data on demographics, daily cumulative psychoactive medication exposure, and severity of illness. We performed daily delirium assessments via the CAM-ICU. We analyzed associations between select single nucleotide polymorphisms (SNPs) and delirium. Results: From June, 2018 through January, 2019, we screened 244 patients and enrolled 50. The median age was 62.0 years old (range: 28-82 years old), and 27 (54%) of the subjects were female. In all, 49 (98%) samples were both high quality and sufficient quantity. In secondary analyses, we found that 80% (12/15) of patients with two 2 copies of a G allele at rs4680 on COMT experienced delirium, whereas 44% (4/9) of patients with 2 copies of an A allele at this location had delirium. In all, 44% (4/9) of patients with 2 T allele copies at rs7439366 on UGT2B7 experienced delirium compared to 73% (11/15) of patients with 2 C allele copies at this location. Conclusions: We can feasibly collect genetic information from critically ill adults. We were able to efficiently collect high quality DNA of sufficient quantity to conduct pharmacogenetic analysis in this critically ill population. Although the sample size of our current study is too small to conduct robust inferential analyses, it suggests potential SNP targets for a future larger study.

Effects by educational attainment of a mammography screening patient decision aid for women aged 75 years and older.

BACKGROUND: To help inform screening decisions, a mammography screening decision aid (DA) for women aged 75 years and older was tested in a cluster randomized clinical trial of 546 women. DA use increased women's knowledge of the benefits and harms of mammography and lowered screening rates. In the current study, the objective was to examine whether participants' views of the DA and/or its effects differed by educational attainment. METHODS: A secondary analysis was conducted of 283 women who received the DA before a personal care provider (PCP) visit during the trial to examine the acceptability of the DA and its effects on knowledge of the benefits and harms of mammography, screening intentions, and receipt of screening by educational attainment. Adjusted analyses accounted for clustering by PCP. RESULTS: Of the 283 participants, 43% had a college education or less. Regardless of educational attainment, 87.2% found the DA helpful. Women with lower educational attainment were less likely to understand all of the DA's content (46.3% vs 67.5%; P < .001), had less knowledge of the benefits and harms of mammography (adjusted mean ± standard error knowledge score, 7.1 ± 0.3 vs 8.1 ± 0.3; P < .001), and were less likely to lower screening intentions (adjusted percentage, 11.4% vs 19.4%; P = .01). Receipt of screening did not differ by educational attainment. CONCLUSIONS: A mammography DA for women aged 75 years and older was helpful to women regardless of their educational attainment; however, those with a college degree or greater understood the DA and, possibly as a result, lowered their screening intentions. Future studies need to examine how to better support informed decision making around mammography screening in older women with lower educational attainment. LAY SUMMARY: The authors examined data from a previous study to learn the effects of a mammography decision aid (DA) for women aged 75 years and older according to their level of education. Overall, women found the DA helpful, but women with lower educational attainment found it harder to understand the benefits and harms of mammography screening and were less likely to lower their screening intentions than women with a college degree. The findings suggest that women aged 75 years and older who have lower educational attainment may need an even lower literacy DA and/or more support from health care professionals.

Screening for Hearing Loss in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Hearing loss is common in older adults and associated with adverse health and social outcomes. Objective: To update the evidence review on screening for hearing loss in adults 50 years or older to inform the US Preventive Services Task Force. Data Sources: MEDLINE, Cochrane Library, EMBASE, and trial registries through January 17, 2020; references; and experts; literature surveillance through October 8, 2020. Study Selection: English-language studies of accuracy, screening, and interventions for screen-detected or newly detected hearing loss. Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality. Meta-analysis of screening test accuracy studies. Main Outcomes and Measures: Quality of life and function, other health and social outcomes, test accuracy, and harms. Results: Forty-one studies (N = 26 386) were included, 18 of which were new since the previous review. One trial enrolling US veterans (n = 2305) assessed the benefits of screening; there was no significant difference in the proportion of participants experiencing a minimum clinically important difference in hearing-related function at 1 year (36%-40% in the screened groups vs 36% in the nonscreened group). Thirty-four studies (n = 23 228) evaluated test accuracy. For detecting mild hearing loss (>20-25 dB), single-question screening had a pooled sensitivity of 66% (95% CI, 58%-73%) and a pooled specificity of 76% (95% CI, 68%-83%) (10 studies, n = 12 637); for detecting moderate hearing loss (>35-40 dB), pooled sensitivity was 80% (95% CI, 68%-88%) and pooled specificity was 74% (95% CI, 59%-85%) (6 studies, n = 8774). In 5 studies (n = 2820) on the Hearing Handicap Inventory for the Elderly-Screening to detect moderate hearing loss (>40 dB), pooled sensitivity was 68% (95% CI, 52%-81%) and pooled specificity was 78% (95% CI, 67%-86%). Six trials (n = 853) evaluated amplification vs control in populations with screen-detected or recently detected hearing loss over 6 weeks to 4 months. Five measured hearing-related function via the Hearing Handicap Inventory for the Elderly; only 3 that enrolled veterans (n = 684) found a significant difference considered to represent a minimal important difference (>18.7 points). Few trials reported on other eligible outcomes, and no studies reported on harms of screening or interventions. Conclusions and Relevance: Several screening tests can adequately detect hearing loss in older adults; no studies reported on the harms of screening or treatment. Evidence showing benefit from hearing aids on hearing-related function among adults with screen-detected or newly detected hearing loss is limited to studies enrolling veterans.

Evaluating the care provision of a community-based serious-illness care program via chart measures.

BACKGROUND: Although quality-of-care domains for home-based primary and palliative programs have been proposed, they have had limited testing in practice. Our aim was to evaluate the care provision in a community-based serious-illness care program, a combined home-based primary and palliative care model. METHODS: Retrospective chart review of patients in an academic community-based serious-illness care program in central North Carolina from August 2014 to March 2016 (n = 159). Chart review included demographics, health status, and operationalized measures of seven quality-of-care domains: medical assessment, care coordination, safety, quality of life, provider competency, goal attainment, and access. RESULTS: Patients were mostly women (56%) with an average age of 70 years. Patients were multi-morbid (53% ≥3 comorbidities), functionally impaired (45% had impairment in ≥2 activities of daily living) and 32% had dementia. During the study period, 31% of patients died. Chart review found high rates assessment of functional status (97%), falls (98%), and medication safety (96%). Rates of pain assessment (70%), advance directive discussions (65%), influenza vaccination (59%), and depression assessment (54% of those with a diagnosis of depression) were lower. Cognitive barriers, spiritual needs, and behavioral issues were assessed infrequently (35, 22, 21%, respectively). CONCLUSION: This study is one of the first to operationalize and examine quality-of-care measures for a community-based serious-illness care program, an emerging model for vulnerable adults. Our operationalization should not constitute validation of these measures and revealed areas for improvement; however, the community-based serious-illness care program performed well in several key quality-of-care domains. Future work is needed to validate these measures.

Primary Care-Based Staff Ideas for Implementing a Mammography Decision Aid for Women 75+: a Qualitative Study.

BACKGROUND: We previously developed a pamphlet decision aid (DA) on mammography screening for women ≥ 75 years. However, implementing DAs in primary care may be challenging and may require support from non-physician healthcare team members. OBJECTIVE: To learn from primary care administrators, nurses, and staff their thoughts on how best to implement a mammography DA for women ≥ 75 years in practice. DESIGN: Qualitative study entailing in-person individual interviews using a semi-structured interview guide. PARTICIPANTS: Thirty-two non-physician healthcare team members (69.6% of those approached) participated from 8 different primary care practices (community and academic) in the Boston area or in Chapel Hill, NC. APPROACH: Participants were asked to provide feedback on the DA, their thoughts on ways to make the DA available to older women, and factors that would make it easier and/or harder to implement. KEY RESULTS: Participants felt the DA was clear, balanced, and understandable, but felt that it needed to be shorter for women with low health literacy. Most participants felt that as long as use of the DA was approved and supported by clinicians that women ≥ 75 years should receive the DA before a visit from staff (usually medical assistants) so that patients could ask their clinicians questions during the visit. Facilitators of DA use included its perceived helpfulness with decision-making, its format, and that existing systems (panel management, electronic medical record alerts) could be accessed to get the DA to patients especially at Medicare Annual Wellness visits. Participants perceived a need for training, albeit minimal, to provide the DA to patients. Barriers of DA use included competing demands on clinician and staff time. CONCLUSIONS: Participants felt that as long as use of the mammography DA for women ≥ 75 years was supported by clinicians, it would be feasible to implement with minimal refinements to existing healthcare system processes.

Development and validation of a 5-year mortality prediction model using regularized regression and Medicare data.

PURPOSE: De-implementation of low-value services among patients with limited life expectancy is challenging. Robust mortality prediction models using routinely collected health care data can enhance health care stakeholders' ability to identify populations with limited life expectancy. We developed and validated a claims-based prediction model for 5-year mortality using regularized regression methods. METHODS: Medicare beneficiaries age 66 or older with an office visit and at least 12 months of pre-visit continuous Medicare A/B enrollment were identified in 2008. Five-year mortality was assessed through 2013. Secondary outcomes included 30-, 90-, and 180-day and 1-year mortality. Claims-based predictors, including comorbidities and indicators of disability, frailty, and functional impairment, were selected using regularized logistic regression, applying the least absolute shrinkage and selection operator (LASSO) in a random 80% training sample. Model performance was assessed and compared with the Gagne comorbidity score in the 20% validation sample. RESULTS: Overall, 183 204 (24%) individuals died. In addition to demographics, 161 indicators of comorbidity and function were included in the final model. In the validation sample, the c-statistic was 0.825 (0.823-0.828). Median-predicted probability of 5-year mortality was 14%; almost 4% of the cohort had a predicted probability greater than 80%. Compared with the Gagne score, the LASSO model led to improved 5-year mortality classification (net reclassification index = 9.9%; integrated discrimination index = 5.2%). CONCLUSIONS: Our claims-based model predicting 5-year mortality showed excellent discrimination and calibration, similar to the Gagne score model, but resulted in improved mortality classification. Regularized regression is a feasible approach for developing prediction tools that could enhance health care research and evaluation of care quality.

Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Intimate partner violence (IPV), elder abuse, and abuse of vulnerable adults are common and result in adverse health outcomes. Objective: To review the evidence on screening and interventions for IPV, elder abuse, and abuse of vulnerable adults to inform the US Preventive Services Task Force. Data Sources: MEDLINE, Cochrane Library, EMBASE, and trial registries through October 4, 2017; references; experts; literature surveillance through August 1, 2018. Study Selection: English-language randomized clinical trials (RCTs), studies evaluating test accuracy, and cohort studies with a concurrent control group assessing harms. Data Extraction and Synthesis: Dual review of titles and abstracts, full-text articles, and study quality; qualitative synthesis of findings. Data were not pooled, primarily because of heterogeneity of populations, interventions, and outcomes. Main Outcomes and Measures: Abuse or neglect, morbidity caused by abuse, test accuracy, and harms. Results: Thirty studies were included (N = 14 959). Three RCTs (n = 3759) compared IPV screening with no screening; none found significant improvements in outcomes (eg, IPV or quality of life) over 3 to 18 months and 2 (n = 935) reported no harms of screening. Nine studies assessed tools to detect any past-year or current IPV in women; for past-year IPV (5 studies [n = 6331]), sensitivity of 5 tools ranged from 65% to 87% and specificity ranged from 80% to 95%. The accuracy of 5 tools (4 studies [n = 1795]) for detecting current abuse varied widely; sensitivity ranged from 46% to 94% and specificity ranged from 38% to 95%. Eleven RCTs (n = 6740) evaluated interventions for women with screen-detected IPV. Two enrolling pregnant women (n = 575) found significantly less IPV among women in the intervention group: 1 home visiting intervention (standardized mean difference [SMD], -0.34 [95% CI, -0.59 to -0.08]) and 1 behavioral counseling intervention for multiple risks (IPV, smoking, depression, tobacco exposure) (SMD, -0.40 [95% CI, -0.68 to -0.12]). No studies evaluated screening or interventions for elder abuse or abuse of vulnerable adults. One study assessing a screening tool for elder abuse had poor accuracy (sensitivity, 46% and specificity, 73% for detecting physical or verbal abuse). Conclusions and Relevance: Although available screening tools may reasonably identify women experiencing IPV, trials of IPV screening in adult women did not show a reduction in IPV or improvement in quality of life over 3 to 18 months. Limited evidence suggested that home visiting and behavioral counseling interventions that address multiple risk factors may lead to reduced IPV among pregnant or postpartum women. No studies assessed screening or treatment for elder abuse and abuse of vulnerable adults.

Design of a randomized clinical trial of a colorectal cancer screening decision aid to promote appropriate screening in community-dwelling older adults.

BACKGROUND: Appropriate colorectal cancer screening in older adults should be aligned with the likelihood of net benefit. In general, patient decision aids improve knowledge and values clarity, but in older adults, they may also help patients identify their individual likelihood of benefit and foster individualized decision-making. We report on the design of a randomized clinical trial to understand the effects of a patient decision aid on appropriate colorectal cancer screening. This report includes a description of the baseline characteristics of participants. METHODS: English-speaking primary care patients aged 70-84 years who were not currently up to date with screening were recruited into a randomized clinical trial comparing a tailored colorectal cancer screening decision aid with an attention control. The intervention group received a decision aid that included a values clarification exercise and individualized decision-making worksheet, while the control group received an educational pamphlet on safe driving behaviors. The primary outcome was appropriate screening at 6 months based on chart review. We used a composite measure to define appropriate screening as screening for participants in good health, a discussion about screening for patients in intermediate health, and no screening for patients in poor health. Health state was objectively determined using patients' Charlson Comorbidity Index score and age. RESULTS: A total of 14 practices in central North Carolina participated as part of a practice-based research network. In total, 424 patients were recruited to participate and completed a baseline visit. Overall, 79% of participants were White and 58% female, with a mean age of 76.8 years. Patient characteristics between groups were similar by age, gender, race, education, insurance coverage, or work status. Overall, 70% had some college education or more, 57% were married, and virtually all had Medicare insurance (90%). The three primary medical conditions among the cohort were a history of diabetes, pneumonia, and cancer (28%, 26%, and 21%, respectively). CONCLUSION: We designed a randomized clinical trial to test a novel use of a patient decision aid to promote appropriate colorectal cancer screening and have recruited a diverse study population that seems similar between the intervention and control groups. The study should be able to determine the ability of a patient decision aid to increase individualized and appropriate colorectal cancer screening.

Nursing home nurses' and community-dwelling older adults' reported knowledge, attitudes, and behavior toward antibiotic use.

BACKGROUND: Antibiotic overuse causes antibiotic resistance, one of the most important threats to human health. Older adults, particularly those in nursing homes, often receive antibiotics when they are not indicated. METHODS: To understand knowledge, attitudes, and behaviors of nursing home (NH) nurses and community-dwelling older adults towards antibiotic use, especially in clinical situations consistent with antibiotic overuse, we conducted a mixed-method survey in two NHs and one Family Medicine clinic in North Carolina, among English-speaking nurses and community-dwelling, cognitively intact adults aged 65 years or older. Based on the Knowledge-Attitude-Practice model, the survey assessed knowledge, attitudes, and behavior towards antibiotic use, including three vignettes designed to elicit possible antibiotic overuse: asymptomatic bacteriuria (ASB), a viral upper respiratory illness (URI), and a wound from a fall. RESULTS: Of 31 NH nurses and 66 community-dwelling older adults, 70% reported knowledge of the dangers of taking antibiotics. Nurses more often reported evidence-based attitudes towards antibiotics than older adults, except 39% agreed with the statement "by the time I am sick enough to go to the doctor with a cold, I expect an antibiotic", while only 28% of older adults agreed with it. A majority of nurses did not see the need for antibiotics in any of the three vignettes: 77% for the ASB vignette, 87% for the URI vignette, and 97% for the wound vignette. Among older adults, 50% did not perceive a need for antibiotics in the ASB vignette, 58% in the URI vignette, and 74% in the wound vignette. CONCLUSIONS: While a substantial minority had no knowledge of the dangers of antibiotic use, non-evidence-based attitudes towards antibiotics, and behaviors indicating inappropriate management of suspected infections, most NH nurses and community-dwelling older adults know the harms of antibiotic use and demonstrate evidence-based attitudes and behaviors. However, more work is needed to improve the knowledge, attitudes and behaviors that may contribute to antibiotic overuse.

Optimizing Antibiotic Use in Nursing Homes Through Antibiotic Stewardship.

Antibiotic stewardship is becoming a requirement for nursing homes. Programs should be interdisciplinary and multifaceted; should have support from nursing home administrators; and should aim to promote antibiotics only when needed, not just in case. Recommended components include use of evidence-based guidelines; ongoing monitoring of antibiotic prescriptions, cultures, and study results; monitoring of health outcomes; use of nursing home-specific antibiograms; regular reporting and feedback to medical providers and nurses; and education of residents and families.

Comparing 3 values clarification methods for colorectal cancer screening decision-making: a randomized trial in the US and Australia.

PURPOSE: To compare the effects of three methods of values clarification (VCM): balance sheet; rating and ranking; and a discrete choice experiment (DCE) on decision-making about colorectal cancer (CRC) screening among adults in the US and Australia. METHODS: Using online panels managed by a survey research organization in the US and Australia, we recruited adults ages 50-75 at average risk for CRC for an online survey. Those eligible were randomized to one of the three VCM tasks. CRC screening options were described in terms of five key attributes: reduction in risk of CRC incidence and mortality; nature of the screening test; screening frequency; complications from screening; and chance of requiring a colonoscopy (as initial or follow-up testing). Main outcomes included self-reported most important attribute and unlabeled screening test preference by VCM and by country, assessed after the VCM. RESULTS: A total of 920 participants were enrolled; 51 % were Australian; mean age was 59.0; 87.0 % were white; 34.2 % had a 4-year college degree; 42.8 % had household incomes less than $45,000 USD per year; 44.9 % were up to date with CRC screening. Most important attribute differed across VCM groups: the rating and ranking group was more likely to choose risk reduction as most important attribute (69.8 %) than the balance sheet group (54.7 %) or DCE (49.3 %), p < 0.0001; most important attribute did not vary by country (p = 0.236). The fecal occult blood test (FOBT)-like test was the most frequently preferred test overall (55.9 %). Unlabeled test choice did not differ meaningfully by VCM. Australians were more likely to prefer the FOBT (AU 66.2 % vs. US 45.1 %, OR 2.4, 95 % CI 1.8, 3.1). Few participants favored no screening (US: 9.2 %, AU: 6.2 %). CONCLUSIONS: Screening test attribute importance varied by VCM, but not by country. FOBT was more commonly preferred by Australians than by Americans, but test preferences were heterogeneous in both countries.

Pre-post-evaluation of a dementia-specific advance care planning toolkit for Japanese primary care clinicians.

BACKGROUND: The population of people living with dementia (PLwD) continues to grow in Japan where advance care planning (ACP) for PLwD is relatively new. Our aim was to evaluate the feasibility and cultural acceptability of a dementia-specific ACP communication skills toolkit for Japanese primary care clinicians. METHODS: We delivered 13 training sessions in primary care clinics across central Japan and conducted a post-training survey to assess whether the toolkit increased confidence in dementia-specific ACP communication skills and the acceptability of the toolkit with the following four statements: (1) The language in the sessions was clear, (2) The sessions took an appropriate amount of time to complete, (3) The design of the sessions was an effective educational method, and (4) The sessions were culturally appropriate for communication with Japanese patients with dementia and their family members. We asked participants to respond using a 5-point Likert scale from strongly agree to strongly disagree. RESULTS: All participants were Japanese and included 80 physicians (mean age 39.8 years), 33 nurses (mean age 45.7 years), and 58 other participants (mean age 42.9 years), who were 30.0%, 87.9%, and 55.2% female, respectively. Most participants practiced in rural settings. In pre- post-comparisons, participant confidence increased in determining capacity, understanding dementia prognosis, goals of care, eliciting surrogates, recommending self-care practices to families, and leading family meetings (all p < 0.001). Most participants strongly agreed or agreed that the toolkit was an effective method (96.9%), took an appropriate amount of time (94.5%), contained clear language (89.8%), and was culturally appropriate (73.6%). CONCLUSIONS: Dementia-specific ACP communication skills toolkit can be delivered in Japan. Japanese primary care clinicians generally felt the dementia-specific ACP toolkit increased their confidence in ACP communication skills and was acceptable. The language, time, and design were well received, though further work is needed to improve the cultural appropriateness of the toolkit.

Diagnosis of urinary incontinence.

Urinary incontinence is common, increases in prevalence with age, and affects quality of life for men and women. The initial evaluation occurs in the family physician's office and generally does not require urologic or gynecologic evaluation. The basic workup is aimed at identifying possible reversible causes. If no reversible cause is identified, then the incontinence is considered chronic. The next step is to determine the type of incontinence (urge, stress, overflow, mixed, or functional) and the urgency with which it should be treated. These determinations are made using a patient questionnaire, such as the 3 Incontinence Questions, an assessment of other medical problems that may contribute to incontinence, a discussion of the effect of symptoms on the patient's quality of life, a review of the patient's completed voiding diary, a physical examination, and, if stress incontinence is suspected, a cough stress test. Other components of the evaluation include laboratory tests and measurement of postvoid residual urine volume. If the type of urinary incontinence is still not clear, or if red flags such as hematuria, obstructive symptoms, or recurrent urinary tract infections are present, referral to a urologist or urogynecologist should be considered.

Patient-level information underlying overdiagnosis of urinary tract infections in nursing homes: A discrete choice experiment.

The overdiagnosis of urinary tract infections (UTIs) in nursing home residents is a significant public health threat. Using a discrete choice experiment and a diagnostic guideline, we examined which patient-level information was associated with the overdiagnosis of UTIs and found that urinalysis results and lower urinary tract status were most associated.

Black Smokers' Preferences for Features of a Smoking Cessation App: Qualitative Study.

BACKGROUND: Mobile health (mHealth) interventions for smoking cessation have grown extensively over the last few years. Although these interventions improve cessation rates, studies of these interventions consistently lack sufficient Black smokers; hence knowledge of features that make mHealth interventions attractive to Black smokers is limited. Identifying features of mHealth interventions for smoking cessation preferred by Black smokers is critical to developing an intervention that they are likely to use. This may in turn address smoking cessation challenges and barriers to care, which may reduce smoking-related disparities that currently exist. OBJECTIVE: This study aims to identify features of mHealth interventions that appeal to Black smokers using an evidence-based app developed by the National Cancer Institute, QuitGuide, as a reference. METHODS: We recruited Black adult smokers from national web-based research panels with a focus on the Southeastern United States. Participants were asked to download and use QuitGuide for at least a week before participation in remote individual interviews. Participants gave their opinions about features of the QuitGuide app and other mHealth apps they may have used in the past and suggestions for future apps. RESULTS: Of the 18 participants, 78% (n=14) were women, with age ranging from 32 to 65 years. Themes within five major areas relevant for developing a future mHealth smoking cessation app emerged from the individual interviews: (1) content needs including health and financial benefits of quitting, testimonials from individuals who were successful in quitting, and strategies for quitting; (2) format needs such as images, ability to interact with and respond to elements within the app, and links to other helpful resources; (3) functionality including tracking of smoking behavior and symptoms, provision of tailored feedback and reminders to users, and an app that allows for personalization of functions; (4) social network, such as connecting with friends and family through the app, connecting with other users on social media, and connecting with a smoking cessation coach or therapist; and (5) the need for inclusivity for Black individuals, which may be accomplished through the inclusion of smoking-related information and health statistics specific for Black individuals, the inclusion of testimonials from Black celebrities who successfully quit, and the inclusion of cultural relevance in messages contained in the app. CONCLUSIONS: Certain features of mHealth interventions for smoking cessation were highly preferred by Black smokers based on their use of a preexisting mHealth app, QuitGuide. Some of these preferences are similar to those already identified by the general population, whereas preferences for increasing the inclusivity of the app are more specific to Black smokers. These findings can serve as the groundwork for a large-scale experiment to evaluate preferences with a larger sample size and can be applied in developing mHealth apps that Black smokers may be more likely to use.

Pragmatic evaluation of events and benefits of lipid lowering in older adults (PREVENTABLE): Trial design and rationale.

Whether initiation of statins could increase survival free of dementia and disability in adults aged ≥75 years is unknown. PREVENTABLE, a double-blind, placebo-controlled randomized pragmatic clinical trial, will compare high-intensity statin therapy (atorvastatin 40 mg) with placebo in 20,000 community-dwelling adults aged ≥75 years without cardiovascular disease, disability, or dementia at baseline. Exclusion criteria include statin use in the prior year or for >5 years and inability to take a statin. Potential participants are identified using computable phenotypes derived from the electronic health record and local referrals from the community. Participants will undergo baseline cognitive testing, with physical testing and a blinded lipid panel if feasible. Cognitive testing and disability screening will be conducted annually. Multiple data sources will be queried for cardiovascular events, dementia, and disability; survival is site-reported and supplemented by a National Death Index search. The primary outcome is survival free of new dementia or persisting disability. Co-secondary outcomes are a composite of cardiovascular death, hospitalization for unstable angina or myocardial infarction, heart failure, stroke, or coronary revascularization; and a composite of mild cognitive impairment or dementia. Ancillary studies will offer mechanistic insights into the effects of statins on key outcomes. Biorepository samples are obtained and stored for future study. These results will inform the benefit of statins for increasing survival free of dementia and disability among older adults. This is a pioneering pragmatic study testing important questions with low participant burden to align with the needs of the growing population of older adults.

Geriatric Care in the Community Setting: When Older Adults Can No Longer Live Alone at Home.

Older adults living alone at home are at risk of many adverse outcomes, including injuries from falls, firearms, and driving; adverse drug events due to drug errors; and self-neglect or elder abuse. An estimated 4.5 million Medicare beneficiaries became homebound between 2012 and 2018. Becoming homebound increases the risk of harm for older adults. Clinicians should evaluate the home safety of older adult patients, which requires assessing their medical conditions, home physical environment, and social circumstances. Identified problems should be addressed with interventions that allow patients to live safely in the least restrictive environment possible. The least restrictive interventions are in-home modifications (eg, installation of handrails and grab bars) and use of remote monitoring, in-home services, and shopping and transportation services. Daytime participation in senior centers or adult day care also can be useful. Some patients will require a change in living situation, with a move to senior housing or retirement communities, group homes, assisted living communities, skilled nursing facilities, or the home of a family member. Some of these alternative living situations require financial resources that a patient or family members may not have. Public assistance is available in some cases, if patients meet eligibility requirements.

Feasibility of Algorithm-Based Clinical Decision Support for Suspected Urinary Tract Infections in Nursing Home Residents.

Urinary tract infections (UTIs) are commonly suspected in nursing home (NH) residents, commonly resulting in antimicrobial prescriptions, even when symptoms are non-specific. To improve the diagnosis and management of suspected UTIs in NH residents, we conducted a pilot test of a paper-based clinical algorithm across NHs in the southern U.S. with ten advanced practice providers (APPs). The paper-based algorithm was modified based on the clinical care needs of our APPs and included antimicrobial treatment recommendations. The APPs found the UTI antimicrobial stewardship and clinical decision support acceptable. The educational sessions and algorithm improved baseline confidence toward UTI diagnosing and treatment. The APPs thought the algorithm was useful and did not negatively impact workload. Feedback from the pilot study will be used to improve the next iteration of the algorithm as we assess its impact on prescribing outcomes.