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Randomized trial to improve fracture prevention in nursing home residents.

ABSTRACT: Interventions to improve the fracture prevention in nursing homes are needed.Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n=67) with > or =10 residents with a diagnosis of osteoporosis or recent hip fracture (n=606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering.No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant (P=.72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9-12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1-18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models.Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities.

SUBMITTER: Colon-Emeric CS

PROVIDER: S-EPMC2288656 | biostudies-literature | 2007 Oct

REPOSITORIES: biostudies-literature

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Randomized trial to improve fracture prevention in nursing home residents.

Colón-Emeric Cathleen S CS Lyles Kenneth W KW House Paul P Levine Deborah A DA Schenck Anna P AP Allison Jeroan J Gorospe Joel J Fermazin Mary M Oliver Kristi K Curtis Jeffrey R JR Weissman Norman N Xie Aiyuan A Saag Kenneth G KG

The American journal of medicine 20071001 10

<h4>Background</h4>Interventions to improve the fracture prevention in nursing homes are needed.<h4>Methods</h4>Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n=67) with > or =10 residents with a diagnosis of osteoporosis or recent hip fracture (n=606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstra ...[more]

PMID: 17904460

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Project description:Clinicians struggle with whether to prescribe osteoporosis medications for fracture prevention for older nursing home (NH) residents with dementia, given the lack of evidence in this population. To better understand real-world clinical practice, we conducted a retrospective cohort study examining patterns of fracture prevention medication use for older NH residents with dementia and high fracture risk. Data sources included 2015-16 Medicare claims, Part D prescriptions, and Minimum Data Set (MDS) assessments. Among NH residents aged 65+ with dementia and prior fracture or high fracture risk based on the MDS FRAiL (Fracture Risk Assessment in Long-term care), we assessed medications for fracture prevention using prescription data from 1 year prior through 90 days after the first MDS assessment. Multivariable logistic regression was used to evaluate factors associated with receiving treatment. Most of the sample (n = 72,639) was >80 years (78%), female (82%), and white (88%); 63% had moderate/severe dementia and 60% had an osteoporosis diagnosis. Only 11.6% received fracture prevention medications. In adjusted analyses, treated residents were more likely to be female, Hispanic or other non-black minority, <90 years old, and newly admitted to the NH. Other associated factors included osteoporosis diagnosis, walker or wheelchair use, bone disorders (eg, Paget disease), >5 medications, steroid or proton pump inhibitor use, and regions outside of the Northeast. Resident characteristics suggestive of comorbidity burden and worsening dementia were associated with reduced likelihood of treatment. Low use of fracture prevention medications for NH residents with dementia may reflect an attempt by prescribers reconcile medication use with changing goals of care, or inappropriate underuse in patients who still have high fracture risk. Additional research is needed to help clinicians better evaluate when to use these medications in this heterogeneous and vulnerable population.

Project description:ImportanceIndwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs). Inadequate care of residents with these devices contributes to high rates of multidrug-resistant organisms (MDROs) and device-related infections in NHs.ObjectiveTo test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections.Design, setting, and participantsRandomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both.InterventionsMultimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education.Main outcomes and measuresThe primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident's participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables.ResultsIn total, 418 NH residents with indwelling devices were enrolled, with 34,174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections.Conclusions and relevanceOur multimodal TIP intervention reduced the overall MDRO prevalence density, new methicillin-resistant S aureus acquisitions, and clinically defined catheter-associated urinary tract infection rates in high-risk NH residents with indwelling devices. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals.Trial registrationclinicaltrials.gov Identifier: NCT01062841.

Project description:Little is known regarding outcomes after hip fracture among long-term nursing home residents.To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture.Retrospective cohort study of 60,111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009.Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture.Of 60,111 patients, 21,766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ?75 years: hazard ratio [HR], 2.17; 95% CI, 2.09-2.26 [P?<?.001]), nonoperative fracture management (vs internal fixation: HR for death, 2.08; 95% CI, 2.01-2.15 [P?<?.001]), and advanced comorbidity (Charlson score of ?5 vs 0: HR, 1.66; 95% CI, 1.58-1.73 [P?<?.001]). The combined risk of death or new total dependence in locomotion within 180 days was greatest among patients with very severe cognitive impairment (vs intact cognition: relative risk [RR], 1.66; 95% CI, 1.56-1.77 [P?<?.001]), patients receiving nonoperative management (vs internal fixation: RR, 1.48; 95% CI, 1.45-1.51 [P?<?.001]), and patients older than 90 years (vs ?75 years: RR, 1.42; 95% CI, 1.37-1.46 [P?<?.001]).Survival and functional outcomes are poor after hip fracture among nursing home residents, particularly for patients receiving nonoperative management, the oldest old, and patients with multiple comorbidities and advanced cognitive impairment. Care planning should incorporate appropriate prognostic information related to outcomes in this population.

Project description:BACKGROUND/OBJECTIVES:Secondary prevention medications are recommended for older adults after acute myocardial infarction (AMI), but little is known about whether nursing home (NH) residents receive these medications. The objective was to evaluate new use of secondary prevention medications after AMI in NH residents who were previously nonusers and to evaluate what factors were associated with use. DESIGN:Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. SETTING:U.S. NHs. PARTICIPANTS:National cohort of 11,192 NH residents aged 65 and older who were hospitalized for an AMI between May 2007 and March 2010, had no beta-blocker or statin use for 4 months or longer before the hospitalization, and survived 14 days or more after NH readmission. MEASUREMENTS:The outcome was the number of secondary prevention medications initiated within 30 days of NH readmission. RESULTS:Thirty-seven percent of residents had no secondary prevention medications initiated after AMI, 41% had 1 initiated, and 22% had 2 initiated. After covariate adjustment, fewer secondary prevention medications were used in older residents (proportional odds ratio (POR) = 0.48, 95% confidence interval (CI) = 0.40-0.57 for ?95 vs 65-74); women (POR = 0.88, 95% CI = 0.80-0.96);and those with a do-not-resuscitate (DNR) order (POR = 0.90, 95% CI = 0.83-0.98), functional impairment (dependent or totally dependent vs independent to limited assistance, POR = 0.77, 95% CI = 0.69-0.86), and cognitive impairment (moderate to severe vs no impairment, POR = 0.79, 95% CI = 0.70-0.89). CONCLUSION:More than one-third of older NH residents in the United States do not have any secondary prevention medications initiated after AMI, with fewer medications initiated in older residents; women; and those with, DNR orders, poor physical function, and cognitive impairment. A lack of evidence about the safety and effectiveness of secondary preventions medications in the NH population and unmeasured person-centered goals of care are plausible explanations for these findings.

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Randomized trial to improve fracture prevention in nursing home residents.

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Randomized trial to improve fracture prevention in nursing home residents.

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