May 4, 2015

Grants & Awards


Latest TREC newsletter out.

Read up on all the latest news on TREC’s research and meet members of the team.

New book of interest:
Complex Interventions in Health An overview of research methods
Includes chapter by Drs. Elizabeth J Dogherty and Carole A Estabrooks

This book places complex interventions within a coherent system of research enquiry, this work is designed to help researchers understand the research processes involved at each stage of developing, testing, evaluating and implementing complex interventions, and assist them to integrate methodological activities to produce secure, evidence-based health care interventions. It begins with conceptual chapters which set out the complex interventions framework, discuss the interrelation between knowledge development and evidence, and explore how mixed methods research contributes to improved health.

New articles by Dr. Kim Fraser
Improving Decision making On Location of Care with the frail Elderly and their caregivers (the DOLCE study): study protocol for a cluster randomized controlled trial.
Non UofA Access
Legare F, Briere N, Stacey D, Bourassa H, Desroches S, Dumont S, et al.
Trials 2015 Feb 12;16(1):50-015-0567-7

One of the toughest decisions faced by elderly people is whether to stay at home or move to a care facility. This study seeks to evaluate the impact of training interprofessional home-care teams in shared decision making combined with a decision aid on the proportion of elderly people who report being active in the decision-making process regarding whether to stay at home or move to a care facility. METHODS/DESIGN: We propose a multicenter cluster randomized trial conducted with home-care interprofessional teams in the Province of Quebec with 2 data collection phases: before and after the intervention. Units of randomization will be centers for primary healthcare and social services. We will enroll 16 of these and ask each to provide one home-care interprofessional team involved in decisions and care planning with eligible clients. Clients will be included if they i) are aged ≥65; ii) are receiving care from the participating home-care interprofessional team; iii) have faced the decision about staying at home or moving to a care facility in the past 3 to 6 months; iv) are able to read, understand and write French or English; and v) are able to give informed consent. If clients are unable to provide informed consent, their primary caregiver who was involved in the decision-making process will be eligible to participate. The intervention arm will receive training in shared decision making and use of a decision aid. The control arm will receive ‘usual care’. The primary outcome of interest is the assumed role in the decision-making process as assessed in clients or caregivers with a modified version of the Control Preferences Scale. Multilevel modeling will be used to take the hierarchical structure of the data into account. The study has obtained full ethical approval. The trial will comply with CONSORT guidelines adapted for cluster randomized trials. DISCUSSION: Home care is a rapidly growing sector and this study will lay the foundations of a national strategy to ensure that IP home-care teams provide the highest quality of care for seriously ill elderly people and support for their families. TRIAL REGISTRATION: NCT02244359 (registered 18 September 2014).

Does the quality of life construct as illustrated in quantitative measurement tools reflect the perspective of people with dementia?
Non UofA Access
O’Rourke HM, Fraser KD, Duggleby W.
Journal of advanced nursing 2015 Apr 20

A discussion of the extent to which people with dementia’s perspectives on quality of life have been included in quantitative research. BACKGROUND: Capturing the perspective of people with dementia may improve understanding of their quality of life. Quantitative tools to assess quality of life exist, but the extent to which these reflect the perspective of people with dementia has not been evaluated. DESIGN: A discussion paper. DATA SOURCES: Ten tools (designed between 1992-2012) to measure quality of life from the perspective of people with dementia were located from existing reviews. DISCUSSION: Each tool was rated according to the extent to which the developers included the perspectives of people with dementia at three different points of quality of life conceptualization: during quality of life assessment, to identify quality of life domains and to define an overall conceptual framework. This analysis demonstrates that tool developers were inconsistent in their approach to including the perspectives of people with dementia to understand quality of life. The perspective of people with dementia was included primarily to assess, but not to select domains or define overall quality of life. IMPLICATIONS FOR NURSING: Nurses should consider not only who assesses quality of life, but also whose understanding of quality of life is being assessed. CONCLUSION: It is unclear whether the quantitative quality of life literature reflects the perspective of people with dementia. Debate is needed regarding the impact of this issue on the lives of people with dementia. © 2015 John Wiley & Sons Ltd.

New article by Dr. Janet Squires
Hiding in plain sight: communication theory in implementation science
Non UofA Access
Manojlovich M, Squires JE, Davies B, Graham ID.
Implementation science 2015 Apr 23;10(1):58

Poor communication among healthcare professionals is a pressing problem, contributing to widespread barriers to patient safety. The word “communication” means to share or make common. In the literature, two communication paradigms dominate: (1) communication as a transactional process responsible for information exchange, and (2) communication as a transformational process responsible for causing change. Implementation science has focused on information exchange attributes while largely ignoring transformational attributes of communication. In this paper, we debate the merits of encompassing both paradigms. DISCUSSION: We conducted a two-staged literature review searching for the concept of communication in implementation science to understand how communication is conceptualized. Twenty-seven theories, models, or frameworks were identified; only Rogers’ Diffusion of Innovations theory provides a definition of communication and includes both communication paradigms. Most models (notable exceptions include Diffusion of Innovations, The Ottawa Model of Research Use, and Normalization Process Theory) describe communication as a transactional process. But thinking of communication solely as information transfer or exchange misrepresents reality. We recommend that implementation science theories (1) propose and test the concept of shared understanding when describing communication, (2) acknowledge that communication is multi-layered, identify at least a few layers, and posit how identified layers might affect the development of shared understanding, (3) acknowledge that communication occurs in a social context, providing a frame of reference for both individuals and groups, (4) acknowledge the unpredictability of communication (and healthcare processes in general), and (5) engage with and draw on work done by communication theorists. Implementation science literature has conceptualized communication as a transactional process (when communication has been mentioned at all), thereby ignoring a key contributor to implementation intervention success. When conceptualized as a transformational process, the focus of communication moves to shared understanding and is grounded in human interactions and the way we go about constructing knowledge. Instead of hiding in plain sight, we suggest explicitly acknowledging the role that communication plays in our implementation efforts. By using both paradigms, we can investigate when communication facilitates implementation, when it does not, and how to improve it so that our implementation and clinical interventions are embraced by clinicians and patients alike.

Grants & Awards

TVN call for large scale projects
Further details will be announced in June

TVN is providing advance notice of a new, research call to open in mid-2015 for large scale projects that have the potential to be transformative to the Canadian health care system. Proposals submitted for this research competition must target frail elderly Canadians, as identified by accepted and validated measures of frailty, and address at least one of TVN’s four research themes:
1. Improvement of end-of-life and advance care planning
2. Improvement of acute and critical care
3. Optimization of community and residential care
4. Optimization of transitions of care
Proposals must be interprovincial and interdisciplinary in nature; identifying large-scale, multi-year and measurably impactful projects. To reflect the needs and values of Canadians, especially the frail elderly, and to provide the best opportunity for relevant clinical care practice and policy outcomes, funded research must incorporate meaningful citizen/patient engagement. Successful applicants also will have identified effective partnerships that bring significant (50%) cash and/or in-kind contributions to support and sustain research undertakings and knowledge translation activities. TVN is providing this advance notice so that interested Project Leaders can begin to assemble their panCanadian project teams and secure key partner commitments

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Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Practice and Methodology


The contribution of conceptual frameworks to knowledge translation interventions in physical therapy Canada-flat-icon
Non UofA Access
Hudon A, Gervais MJ, Hunt M.
Physical therapy 2015 Apr;95(4):630-639

There is growing recognition of the importance of knowledge translation activities in physical therapy to ensure that research findings are integrated into clinical practice, and increasing numbers of knowledge translation interventions are being conducted. Although various frameworks have been developed to guide and facilitate the process of translating knowledge into practice, these tools have been infrequently used in physical therapy knowledge translation studies to date. Knowledge translation in physical therapy implicates multiple stakeholders and environments and involves numerous steps. In light of this complexity, the use of explicit conceptual frameworks by clinicians and researchers conducting knowledge translation interventions is associated with a range of potential benefits. This perspective article argues that such frameworks are important resources to promote the uptake of new evidence in physical therapist practice settings. Four key benefits associated with the use of conceptual frameworks in designing and implementing knowledge translation interventions are identified, and limits related to their use are considered. A sample of 5 conceptual frameworks is evaluated, and how they address common barriers to knowledge translation in physical therapy is assessed. The goal of this analysis is to provide guidance to physical therapists seeking to identify a framework to support the design and implementation of a knowledge translation intervention. Finally, the use of a conceptual framework is illustrated through a case example. Increased use of conceptual frameworks can have a positive impact on the field of knowledge translation in physical therapy and support the development and implementation of robust and effective knowledge translation interventions that help span the research-practice gap. © 2015 American Physical Therapy Association.

Facilitating large-scale implementation of evidence based health care: insider accounts from a co-operative inquiry.
Non UofA Access
Waterman H, Boaden R, Burey L, Howells B, Harvey G, Humphreys J, et al.
BMC health services research 2015 Feb 13;15:60-015-0722-6

Facilitators are known to be influential in the implementation of evidence-based health care (EBHC). However, little evidence exists on what it is that they do to support the implementation process. This research reports on how knowledge transfer associates (KTAs) working as part of the UK National Institute for Health Research ‘Collaboration for Leadership in Applied Health Research and Care’ for Greater Manchester (GM CLAHRC) facilitated the implementation of EBHC across several commissioning and provider health care agencies. METHODS: A prospective co-operative inquiry with eight KTAs was carried out comprising of 11 regular group meetings where they reflected critically on their experiences. Twenty interviews were also conducted with other members of the GM CLAHRC Implementation Team to gain their perspectives of the KTAs facilitation role and process. RESULTS: There were four phases to the facilitation of EBHC on a large scale: (1) Assisting with the decision on what EBHC to implement, in this phase, KTAs pulled together people and disparate strands of information to facilitate a decision on which EBHC should be implemented; (2) Planning of the implementation of EBHC, in which KTAs spent time gathering additional information and going between key people to plan the implementation; (3) Coordinating and implementing EBHC when KTAs recruited general practices and people for the implementation of EBHC; and (4) Evaluating the EBHC which required the KTAs to set up (new) systems to gather data for analysis. Over time, the KTAs demonstrated growing confidence and skills in aspects of facilitation: research, interpersonal communication, project management and change management skills. CONCLUSION: The findings provide prospective empirical data on the large scale implementation of EBHC in primary care and community based organisations focusing on resources and processes involved. Detailed evidence shows facilitation is context dependent and that ‘one size does not fits all’. Co-operative inquiry was a useful method to enhance KTAs learning. The evidence shows that facilitators need tailored support and education, during the process of implementation to provide them with a well-rounded skill-set. Our study was not designed to demonstrate how facilitators contribute to patient health outcomes thus further prospective research is required.

Transforming Patient-Centered Care: Development of the Evidence Informed Decision Making through Engagement Model
Non UofA Access
Moore JE, Titler MG, Low LK, Dalton VK, Sampselle CM.
Women’s health issues 2015 Apr 9

In response to the passage of the Affordable Care Act in the United States, clinicians and researchers are critically evaluating methods to engage patients in implementing evidence-based care to improve health outcomes. However, most models on implementation only target clinicians or health systems as the adopters of evidence. Patients are largely ignored in these models. A new implementation model that captures the complex but important role of patients in the uptake of evidence may be a critical missing link. DISCUSSION: Through a process of theory evaluation and development, we explore patient-centered concepts (patient activation and shared decision making) within an implementation model by mapping qualitative data from an elective induction of labor study to assess the model’s ability to capture these key concepts. The process demonstrated that a new, patient-centered model for implementation is needed. In response, the Evidence Informed Decision Making through Engagement Model is presented. We conclude that, by fully integrating women into an implementation model, outcomes that are important to both the clinician and patient will improve. CONCLUSIONS: In the interest of providing evidence-based care to women during pregnancy and childbirth, it is essential that care is patient centered. The inclusion of concepts discussed in this article has the potential to extend beyond maternity care and influence other clinical areas. Utilizing the newly developed Evidence Informed Decision Making through Engagement Model provides a framework for utilizing evidence and translating it into practice while acknowledging the important role that women have in the process. Copyright © 2015 Jacobs Institute of Women’s Health.

Making sense of implementation theories, models and frameworks
Non UofA Access
Nilsen P.
Implementation science 2015 Apr 21;10(1):53

Implementation science has progressed towards increased use of theoretical approaches to provide better understanding and explanation of how and why implementation succeeds or fails. The aim of this article is to propose a taxonomy that distinguishes between different categories of theories, models and frameworks in implementation science, to facilitate appropriate selection and application of relevant approaches in implementation research and practice and to foster cross-disciplinary dialogue among implementation researchers. DISCUSSION: Theoretical approaches used in implementation science have three overarching aims: describing and/or guiding the process of translating research into practice (process models); understanding and/or explaining what influences implementation outcomes (determinant frameworks, classic theories, implementation theories); and evaluating implementation (evaluation frameworks). This article proposes five categories of theoretical approaches to achieve three overarching aims. These categories are not always recognized as separate types of approaches in the literature. While there is overlap between some of the theories, models and frameworks, awareness of the differences is important to facilitate the selection of relevant approaches. Most determinant frameworks provide limited “how-to” support for carrying out implementation endeavours since the determinants usually are too generic to provide sufficient detail for guiding an implementation process. And while the relevance of addressing barriers and enablers to translating research into practice is mentioned in many process models, these models do not identify or systematically structure specific determinants associated with implementation success. Furthermore, process models recognize a temporal sequence of implementation endeavours, whereas determinant frameworks do not explicitly take a process perspective of implementation.

Usage of an online tool to help policymakers better engage with research: Web CIPHER.
Non UofA Access
Makkar SR, Gilham F, Williamson A, Bisset K.
Implementation science 2015 Apr 23;10(1):56

There is a need to develop innovations that help policymakers better engage with research in order to increase its use in policymaking. As part of the Centre for Informing Policy in Health with Evidence from Research (CIPHER), we established Web CIPHER, an online tool with dynamic interactive elements such as hot topics, research summaries, blogs from trusted figures in health policy and research, a community bulletin board, multimedia section and research portal. The aim of this study was to examine policymakers’ use of the website, and determine which sections were key drivers of use. METHODS: Google Analytics (GA) was used to gather usage data during a 16-month period. Analysis was restricted to Web CIPHER members from policy agencies. We examined descriptive statistics including mean viewing times, number of page visits and bounce rates for each section and performed analyses of variance to compare usage between sections. Repeated measures analyses were undertaken to examine whether a weekly reminder email improved usage of Web CIPHER, particularly for research-related content. RESULTS: During the measurement period, 223 policymakers from more than 32 organisations joined Web CIPHER. Users viewed eight posts on average per visit and stayed on the site for approximately 4 min. The bounce rate was less than 6%. The Blogs and Community sections received more unique views than all other sections. Blogs relating to improving policymakers’ skills in applying research to policy were particularly popular. The email reminder had a positive effect on improving usage, particularly for research-related posts. CONCLUSIONS: The data indicated a relatively small number of users. However, this sample may not be representative of policymakers since membership to the site and usage was completely voluntarily. Nonetheless, those who used the site appeared to engage well with it. The findings suggest that providing blog-type content written by trusted experts in health policy and research as well as regular email reminders may provide an effective means of disseminating the latest research to policymakers through an online web portal.

A qualitative study of the variable effects of audit and feedback in the ICU
Non UofA Access Canada-flat-icon
Sinuff T, Muscedere J, Rozmovitz L, Dale CM, Scales DC.
BMJ Quality & Safety 2015

Audit and feedback is integral to performance improvement and behaviour change in the intensive care unit (ICU). However, there remain large gaps in our understanding of the social experience of audit and feedback and the mechanisms whereby it can be optimised as a quality improvement strategy in the ICU setting. Methods We conducted a modified grounded theory qualitative study. Seventy-two clinicians from five academic and five community ICUs in Ontario, Canada, were interviewed. Team members reviewed interview transcripts independently. Data analysis used constant comparative methods. Results Clinicians interviewed experienced audit and feedback as fragmented and variable in its effectiveness. Moreover, clinicians felt disconnected from the process. The audit process was perceived as being insufficiently transparent. Feedback was often untimely, incomplete and not actionable. Specific groups such as respiratory therapists and night-shift clinicians felt marginalised. Suggestions for improvement included improving information sharing about the rationale for change and the audit process, tools and metrics; implementing peer-to-peer quality discussions to avoid a top-down approach (eg, incorporating feedback into discussions at daily rounds); providing effective feedback which contains specific, transparent and actionable information; delivering timely feedback (ie, balancing feedback proximate to events with trends over time) and increasing engagement by senior management. Conclusions ICU clinicians experience audit and feedback as fragmented communication with feedback being especially problematic. Attention to improving communication, integration of the process into daily clinical activities and making feedback timely, specific and actionable may increase the effectiveness of audit and feedback to affect desired change.

Using conjoint analysis to develop a system to score research engagement actions by health decision makers
Makkar S, Williamson A, Turner T, Redman S, Louviere J.
Health Research Policy and Systems 2015;13(1):22

ffective use of research to inform policymaking can be strengthened by policymakers undertaking various research engagement actions (e.g., accessing, appraising, and applying research). Consequently, we developed a thorough measurement and scoring tool to assess whether and how policymakers undertook research engagement actions in the development of a policy document. This scoring tool breaks down each research engagement action into its key ‘subactions’ like a checklist. The primary aim was to develop the scoring tool further so that it assigned appropriate scores to each subaction based on its effectiveness for achieving evidence-informed policymaking. To establish the relative effectiveness of these subactions, we conducted a conjoint analysis, which was used to elicit the opinions and preferences of knowledge translation experts. Method Fifty-four knowledge translation experts were recruited to undertake six choice surveys. Respondents were exposed to combinations of research engagement subactions called ‘profiles’, and rated on a 1–9 scale whether each profile represented a limited (1–3), moderate (4–6), or extensive (7–9) example of each research engagement action. Generalised estimating equations were used to analyse respondents’ choice data, where a utility coefficient was calculated for each subaction. A large utility coefficient indicates that a subaction was influential in guiding experts’ ratings of extensive engagement with research. Results The calculated utilities were used as the points assigned to the subactions in the scoring system. The following subactions yielded the largest utilities and were regarded as the most important components of engaging with research: searching academic literature databases, obtaining systematic reviews and peer-reviewed research, appraising relevance by verifying its applicability to the policy context, appraising quality by evaluating the validity of the method and conclusions, engaging in thorough collaborations with researchers, and undertaking formal research projects to inform the policy in question. Conclusions We have generated an empirically-derived and context-sensitive method of measuring and scoring the extent to which policymakers engaged with research to inform policy development. The scoring system can be used by organisations to quantify staff research engagement actions and thus provide them with insights into what types of training, systems, and tools might improve their staff’s research use capacity.

Leadership for Knowledge Translation: The Case of CLAHRCs.
Non UofA Access
Spyridonidis D, Hendy J, Barlow J.
Qualitative health research 2015 Apr 22

Calls for successful knowledge translation (KT) in health care have multiplied over recent years. The National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) program is a policy initiative in the United Kingdom aimed at speeding-up the translation of research into health care practice. Using multiple qualitative research methods and drawing on the ongoing processes used by individuals to interpret and contextualize information, we explore how new organizational forms for KT bridge the gap between research and practice. We pay particular attention to the relationship between the organization and practices of KT and leadership. Our empirical data demonstrate how the relationship between leadership and KT shifted over time from a push model where the authoritarian top-down leadership team set outcome measures by which to judge KT performance to one which aimed to distribute leadership capacity across a wide range of stakeholders in health and social care systems. The relationship between the organization and practices of KT and leadership is affected by local contextual influences on policies directed at increasing the uptake of research in clinical practice. Policy makers and service leaders need to recognize that more dispersed type of leadership is needed to accommodate the idiosyncratic nature of collective action. © The Author(s) 2015.

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Health Care Administration and Organization

Educational gaps and solutions for early-career nurse managers’ education and participation in quality improvement.
Non UofA Access
Djukic M, Kovner CT, Brewer CS, Fatehi F, Jun J.
The Journal of nursing administration 2015 Apr;45(4):206-211

The objective of this study was to examine early-career frontline nurse managers’ (FLNMs’) reported educational preparedness and participation in quality improvement (QI). BACKGROUND: Frontline nurse managers are vitally important for leading QI. However, it is not well known if they have adequate knowledge and skills to lead this important function. METHODS: We examined cross-sectional survey data from 42 FLNMs using descriptive statistics. RESULTS: About 30% of FLNMs reported being very prepared across 12 measured QI skills by schools or employers and 35% reported participating in a specific clinical effort to improve patient care on their unit more than once a month. More than 50% reported having good organizational support for QI, but only about 30% reported being rewarded for their contributions to QI. CONCLUSION: Our study highlights opportunities for development in QI for FLNMs and offers some solutions for nurse executives that can bridge the educational gaps.

Nursing staff interactions during the older residents’ transition into long-term care facility in a nursing home in rural Norway: an ethnographic study.
Non UofA Access
Eika M, Dale B, Espnes GA, Hvalvik S.
BMC health services research 2015 Mar 29;15(1):125-015-0818-z

Future challenges in many countries are the recruitment of competent staff in long-term care facilities, and the use of unlicensed staff. Our study describes and explores staff interactions in a long-term care facility, which may facilitate or impede healthy transition processes for older residents in transition. METHODS: An ethnographic study based on fieldwork following ten older residents admission day and their initial week in the long-term care facility, seventeen individual semi-structured interviews with different nursing staff categories and the leader of the institution, and reading of relevant documents. RESULTS: The interaction among all staff categories influenced the new residents’ transition processes in various ways. We identified three main themes: The significance of formal and informal organization; interpersonal relationships and cultures of care; and professional hierarchy and different scopes of practice. CONCLUSIONS: The continuous and spontaneous staff collaborations were key activities in supporting quality care in the transition period. These interactions maintained the inclusion of all staff present, staff flexibility, information flow to some extent, and cognitive diversity, and the new resident’s emerging needs appeared met. Organizational structures, staff’s formal position, and informal staff alliances were complex and sometimes appeared contradictory. Not all the staff were necessarily included, and the new residents’ needs not always noticed and dealt with. Paying attention to the playing out of power in staff interactions appears vital to secure a healthy transition process for the older residents.

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Health Care Innovation and Quality Assurance

Modeling and evaluating evidence-based continuing education program in nursing home dementia care (MEDCED)-training of care home staff to reduce use of restraint in care home residents with dementia. A cluster randomized controlled trial.
Non UofA Access
Testad I, Mekki TE, Forland O, Oye C, Tveit EM, Jacobsen F, et al.
International journal of geriatric psychiatry 2015 Apr 6

The aim of this study was to evaluate the effectiveness of a tailored 7-month training intervention “Trust Before Restraint,” in reducing use of restraint, agitation, and antipsychotic medications in care home residents with dementia. METHODS: This is a single-blind cluster randomized controlled trial in 24 care homes within the Western Norway Regional Health Authority 2011-2013. RESULTS: From 24 care homes, 274 residents were included in the study, with 118 in the intervention group and 156 in the control group. Use of restraint was significantly reduced in both the intervention group and the control group despite unexpected low baseline, with a tendency to a greater reduction in the control group. There was a significant reduction in Cohen-Mansfield Agitation Inventory score in both the intervention group and the follow-up group with a slightly higher reduction in the control group, although this did not reach significance and a small nonsignificant increase in use of antipsychotics (14.1-17.7%) and antidepressants (35.9-38.4%) in both groups. CONCLUSIONS: This study reports on the statistically significant reduction in use of restraint in care homes, both prior and during the 7-month intervention periods, in both intervention and control groups. When interpreted within the context of the current climate of educational initiatives to reduce restraint and a greater focus on the importance of person-centered care, the study also highlights the potential success achieved with national training programs for care staff and should be further evaluated to inform future training initiatives both in Norway and internationally. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Quantitative assessment of organizational culture within hospitals and its relevance to infection prevention and control strategies.
Non UofA Access
Borg MA, Waisfisz B, Frank U.
The Journal of hospital infection 2015 May;90(1):75-77

t has been suggested that organizational culture (OC) is an important driver of infection prevention and control (IPC) behaviour among healthcare workers. This study examined OC in seven European hospitals using a validated assessment tool based on Hofstede’s model, and identified significant variations in OC scores. Hospitals with low prevalence of meticillin-resistant Staphylococcus aureus (MRSA) exhibited high scores for change facilitation and change readiness, whereas hospitals with high prevalence of MRSA exhibited low scores for these determinants. It is possible to use tools, available outside health care, to study OC within hospitals and gain better insight into IPC behaviour change strategies. Copyright © 2015

Creating a Network of High-Quality Skilled Nursing Facilities: Preliminary Data on the Postacute Care Quality Improvement Experiences of an Accountable Care Organization
Non UofA Access
Lage DE, Rusinak D, Carr D, Grabowski DC, Ackerly DC.
Journal of the American Geriatrics Society 2015;63(4):804-808

Postacute care (PAC) is an important source of cost growth and variation in the Medicare program and is critical to accountable care organization (ACO) and bundled payment efforts to improve quality and value in the Medicare program, but ACOs must often look outside their walls to identify high-value external PAC partners, including skilled nursing facilities (SNFs). As a solution to this problem, the integrated health system, Partners HealthCare System (PHS) and its Pioneer ACO launched the PHS SNF Collaborative Network in October 2013 to identify and partner with high-quality SNFs. This study details the method by which PHS selected SNFs using minimum criteria based on public scores and secondary criteria based on self-reported measures, describes the characteristics of selected and nonselected SNFs, and reports SNF satisfaction with the collaborative. The selected SNFs (n = 47) had significantly higher CMS Five-Star scores than the nonselected SNFs (n = 93) (4.6 vs 3.2, P < .001) and were more likely than nonselected SNFs that met the minimum criteria (n = 35) to have more than 5 days of clinical coverage (17.0% vs 2.9%, P = .02) and to have a physician see admitted individuals within 24 (38.3% vs 17.1%, P = .02) and 48 hours (93.6% vs 80.0%, P = .03). A survey sent to collaborative SNFs found high satisfaction with the process (average satisfaction, 4.6/5, with 1 = very dissatisfied and 5 = very satisfied, n = 19). Although the challenges of improving care in SNFs remain daunting, this approach can serve as a first step toward greater clinical collaboration between acute and postacute settings that will lead to better outcomes for frail older adults.

The most used and most helpful facilitators for patient-centered medical home implementation
Gale R, Asch S, Taylor T, Nelson K, Luck J, Meredith L, et al.
Implementation Science 2015;10(1):52

Like other transformative healthcare initiatives, patient-centered medical home (PCMH) implementation requires substantial investments of time and resources. Even though PCMH and PCMH-like models are being implemented by multiple provider practices and health systems, little is known about what facilitates their implementation. The purpose of this study was to assess which PCMH-implementation resources are most widely used, by whom, and which resources primary care personnel find most helpful. Methods This study is an analysis of data from a cross-sectional survey of primary care personnel in the Veterans Health Administration in 2012, in which respondents were asked to rate whether they were aware of and accessed PCMH-implementation resources, and to rate their helpfulness. Logistic regression was used to produce odds ratios for the outcomes (1) resource use and (2) resource helpfulness. Respondents were nested within clinics, nested, in turn, within 135 parent hospitals. Results Teamlet huddles were the most widely accessed (80.4% accessed) and most helpful (90.4% rated helpful) resource; quality-improvement methods to conduct small tests of change were the least frequently accessed (42.4% accessed) resource though two-thirds (66.7%) of users reported as helpful. Supervisors were significantly more likely (ORs, 1.46 to 1.86) to use resources than non-supervisors but were less likely to rate the majority (8 out of 10) of resources as “somewhat/very helpful” than non-supervisors (ORs, 0.72 to 0.84). Longer-tenured employees tended to rate resources as more helpful. Conclusions These findings are the first in the PCMH literature that we are aware of that systematically assesses primary care staff’s access to and helpfulness of the implementation resources. Supervisors generally reported greater access to resources, relative to non-supervisors, but rated resources as less helpful, suggesting that information about them may not have been optimally disseminated. Knowing what resources primary care staff use and find helpful can inform administrators’ and policymakers’ investments in PCMH-implementation resources. The implications of our model extend beyond just PCMH implementation but also to considerations when providing implementation resources for other complex quality-improvement initiatives.

Caring for the patient, caring for the record: an ethnographic study of ‘back office’ work in upholding quality of care in general practice
Non UofA Access
Swinglehurst D, Greenhalgh T.
BMC health services research 2015 Apr 23;15(1):177-015-0774-7

The quality of information recorded about patient care is considered key to improving the overall quality, safety and efficiency of patient care. Assigning codes to patients’ records is an important aspect of this documentation. Current interest in large datasets in which individual patient data are collated (e.g. proposed NHS project) pays little attention to the details of how ‘data’ get onto the record. This paper explores the work of summarising and coding records, focusing on ‘back office’ practices, identifying contributors and barriers to quality of care. METHODS: Ethnographic observation (187 hours) of clinical, management and administrative staff in two UK general practices with contrasting organisational characteristics. This involved observation of working practices, including shadowing, recording detailed field notes, naturalistic interviews and analysis of key documents relating to summarising and coding. Ethnographic analysis drew on key sensitizing concepts to build a ‘thick description’ of coding practices, drawing these together in a narrative synthesis. RESULTS: Coding and summarising electronic patient records is complex work. It depends crucially on nuanced judgements made by administrators who combine their understanding of: clinical diagnostics; classification systems; how healthcare is organised; particular working practices of individual colleagues; current health policy. Working with imperfect classification systems, diagnostic uncertainty and a range of local practical constraints, they manage a moral tension between their idealised aspiration of a ‘gold standard’ record and a pragmatic recognition that this is rarely achievable in practice. Adopting a range of practical workarounds, administrators position themselves as both formally accountable to their employers (general practitioners), and informally accountability to individual patients, in a coding process which is shaped not only by the ‘facts’ of the case, but by ongoing working relationships which are co-constructed alongside the patient’s summary. CONCLUSION: Data coding is usually conceptualised as either a technical task, or as mundane, routine work, and usually remains invisible. This study offers a characterisation of coding as a socially complex site of moral work through which new lines of accountability are enacted in the workplace, and casts new light on the meaning of coded data as conceptualised in the ‘quality of care’ discourse.

Understanding staff perspectives of quality in practice in healthcare.
Non UofA Access
Farr M, Cressey P.
BMC health services research 2015 Apr 23;15:123-015-0788-1

Extensive work has been focussed on developing and analysing different performance and quality measures in health services. However less has been published on how practitioners understand and assess performance and the quality of care in routine practice. This paper explores how health service staff understand and assess their own performance and quality of their day to day work. Asking staff how they knew they were doing a good job, it explored the values, motivations and behaviours of staff in relation to healthcare performance. The paper illustrates how staff perceptions of quality and performance are often based on different logics to the dominant notions of performance and quality embedded in current policy. METHODS: Using grounded theory and qualitative, in-depth interviews this research studied how primary care staff understood and assessed their own performance and quality in everyday practice. 21 people were interviewed, comprising of health visitors, occupational therapists, managers, human resources staff and administrators. Analytic themes were developed using open and axial coding. RESULTS: Diverse aspects of quality and performance in healthcare are rooted in differing organisational logics. Staff values and personal and professional standards are an essential element in understanding how quality is co-produced in everyday service interactions. Tensions can exist between patient centred, relational care and the pressures of efficiency and rationalisation. CONCLUSIONS: Understanding the perspectives of staff in relation to how quality in practice develops helps us to reflect on different mechanisms to manage quality. Quality in everyday practice relies upon staff values, motivations and behaviours and how staff interact with patients, putting both explicit and tacit knowledge into specific action. However organisational systems that manage quality often operate on the basis of rational measurement. These do not always incorporate the intangible, relational and tacit dimensions of care. Management models need to account for these relational and experiential aspects of care quality to support the prioritisation of patients’ needs. Services management, knowledge management and ethics of care literature can provide stronger theoretical building blocks to understand how to manage quality in practice.

Developing patient-centred care: an ethnographic study of patient perceptions and influence on quality improvement.
Non UofA Access
Renedo A, Marston C.
BMC health services research 2015 Apr 23;15:122-015-0770-y

Understanding quality improvement from a patient perspective is important for delivering patient-centred care. Yet the ways patients define quality improvement remains unexplored with patients often excluded from improvement work. We examine how patients construct ideas of ‘quality improvement’ when collaborating with healthcare professionals in improvement work, and how they use these understandings when attempting to improve the quality of their local services. METHODS: We used in-depth interviews with 23 ‘patient participants’ (patients involved in quality improvement work) and observations in several sites in London as part of a four-year ethnographic study of patient and public involvement (PPI) activities run by Collaborations for Leadership in Applied Health Research and Care for Northwest London. We took an iterative, thematic and discursive analytical approach. RESULTS: When patient participants tried to influence quality improvement or discussed different dimensions of quality improvement their accounts and actions frequently started with talk about improvement as dependent on collective action (e.g. multidisciplinary healthcare professionals and the public), but usually quickly shifted away from that towards a neoliberal discourse emphasising the role of individual patients. Neoliberal ideals about individual responsibility were taken up in their accounts moving them away from the idea of state and healthcare providers being held accountable for upholding patients’ rights to quality care, and towards the idea of citizens needing to work on self-improvement. Participants portrayed themselves as governed by self-discipline and personal effort in their PPI work, and in doing so provided examples of how neoliberal appeals for self-regulation and self-determination also permeated their own identity positions. CONCLUSIONS: When including patient voices in measuring and defining ‘quality’, governments and public health practitioners should be aware of how neoliberal rationalities at the heart of policy and services may discourage consumers from claiming rights to quality care by contributing to public unwillingness to challenge the status quo in service provision. If the democratic potential of patient and public involvement initiatives is to be realised, it will be crucial to help citizens to engage critically with how neoliberal rationalities can undermine their abilities to demand quality care.

The role of institutions on the effectiveness of malaria treatment in the Ghanaian health sector.
Non UofA Access
Amporfu E, Nonvignon J.
BMC health services research 2015 Apr 19;15(1):169-015-0802-7

The Ghanaian health sector has undertaken several policies to help improve the quality of care received by patients. This includes the construction of several health facilities, the increase in the training of health workers, especially nurses, and the introduction of incentive packages (such as salary increase) to motivate health workers. The important question is to what extent does the institutional arrangement between the health facilities and the government as well as between health workers and public health facility administration affect the quality of care? The objective of this study is to find the effect of institutional factors on the quality of care. The institutional factors examined were mainly the extent of decentralization between government and health facilities, as well as between health workers and facility administration, the hiring procedure, and job satisfaction. METHODS: The study used primary data on former patients from sixty six health facilities in three administrative regions of Ghana: the Northern, the Ashanti and the Greater Accra regions. The quality indicator used was effectiveness of treatment as determined by the patient. Ordered logit regression was run for the indicator with patient and health facility characteristics as well as institutional factors as independent variables. The sample size was 2248. RESULTS: The results showed that the patient’s level of formal education had a strong influence on the effectiveness of treatment. In addition, effectiveness of treatment differed according to the administrative region in which the facility was located, and according to the extent of decentralization between health facility and government. The quality of instruments used for treatment, the working conditions for health workers, and job satisfaction had no effect on the effectiveness of treatment. CONCLUSION: Decentralization, the flow of information from government to health facilities and from health facility administrators to health workers are important in ensuring effectiveness. The study recommends further decentralization between health facilities as well as between health workers and administrators. In addition, the study recommends the involvement of health facilities in malaria programs to ensure the flow of information needed for effectiveness of treatment.

The interplay of contextual elements in implementation: an ethnographic case study.
Non UofA Access
McCullough MB, Chou AF, Solomon JL, Petrakis BA, Kim B, Park AM, et al.
BMC health services research 2015 Feb 14;15:62-015-0713-7

Contextual elements have significant impact on uptake of health care innovations. While existing conceptual frameworks in implementation science suggest contextual elements interact with each other, little research has described how this might look in practice. To bridge this gap, this study identifies the interconnected patterns among contextual elements that influence uptake of an anticoagulation clinic improvement initiative. METHODS: We completed 51 semi-structured interviews and ethnographic observations across five case study sites involved in an evidence-based practice (EBP) quality improvement initiative. We analyzed data in NVivo 10 using an a priori approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model and an emergent thematic analysis. RESULTS: Key contextual elements, such as leadership, teamwork, and communication, interacted with each other in contributing to site-level uptake of the EBP, often yielding results that could not be predicted by looking at just one of these elements alone. Sites with context conducive to change in these areas predictably had high uptake, while sites with uniformly weak contextual elements had low uptake. Most sites presented a mixed picture, with contextual elements being strongly supportive of change in some areas and weak or moderate in others. In some cases, we found that sites with strong context in at least one area only needed to have adequate context in other areas to yield high uptake. At other sites, weak context in just one area had the potential to contribute to low uptake, despite countervailing strengths. Even a site with positive views of EBPs could not succeed when context was weak. CONCLUSION: Interrelationships among different contextual elements can act as barriers to uptake at some sites and as facilitators at others. Accounting for interconnections among elements enables PARIHS to more fully describe the determinants of successful implementation as they operate in real-world settings.

Culture change practice in U.S. Nursing homes: prevalence and variation by state medicaid reimbursement policies.
Non UofA Access
Miller SC, Looze J, Shield R, Clark MA, Lepore M, Tyler D, et al.
The Gerontologist 2014 Jun;54(3):434-445

To estimate the prevalence of culture change practice in U.S. nursing homes (NHs) and examine how state Medicaid policies may be associated with this prevalence. DESIGN AND METHODS: In 2009/2010, we conducted a survey of a stratified proportionate random sample of NH directors of nursing (DONs) and administrators (NHAs) at 4,149 U.S. NHs; contact was achieved with 3,695. Cooperation rates were 62.6% for NHAs and 61.5% for DONs. Questions focused on NH (physical) environment, resident-centered care, and staff empowerment domains. Domain scores were created and validated, in part, using qualitative interviews from 64 NHAs. Other NH covariate data were from Medicare/Medicaid surveys (Online Survey, Certification and Reporting), aggregated resident assessments (Minimum Data Set), and Medicare claims. Medicaid policies studied were a state’s average NH reimbursement rate and pay-for-performance (P4P) reimbursement (including and not including culture change performance measures). Multivariate generalized ordered logit regressions were used. RESULTS: Eighty-five percent of DONs reported some culture change implementation. Controlling for NH attributes, a $10 higher Medicaid rate was associated with higher NH environment scores. Compared with NHs in non-P4P states, NHs in states with P4P including culture change performance measures had twice the likelihood of superior culture change scores across all domains, and NHs in other P4P states had superior physical environment and staff empowerment scores. Qualitative interviews supported the validity of survey results. IMPLICATIONS: Changes in Medicaid reimbursement policies may be a promising strategy for increasing culture change practice implementation. Future research examining NH culture change practice implementation pre-post P4P policy changes is recommended.

Relationships, Expertise, Incentives, and Governance: Supporting Care Home Residents’ Access to Health Care. An Interview Study From England.
Non UofA Access
Goodman C, Davies SL, Gordon AL, Meyer J, Dening T, Gladman JR, et al.
Journal of the American Medical Directors Association 2015 Feb 14

To explore what commissioners of care, regulators, providers, and care home residents in England identify as the key mechanisms or components of different service delivery models that support the provision of National Health Service (NHS) provision to independent care homes. METHODS: Qualitative, semistructured interviews with a purposive sample of people with direct experience of commissioning, providing, and regulating health care provision in care homes and care home residents. Data from interviews were augmented by a secondary analysis of previous interviews with care home residents on their personal experience of and priorities for access to health care. Analysis was framed by the assumptions of realist evaluation and drew on the constant comparative method to identify key themes about what is required to achieve quality health care provision to care homes and resident health. RESULTS: Participants identified 3 overlapping approaches to the provision of NHS that they believed supported access to health care for older people in care homes: (1) Investment in relational working that fostered continuity and shared learning between visiting NHS staff and care home staff, (2) the provision of age-appropriate clinical services, and (3) governance arrangements that used contractual and financial incentives to specify a minimum service that care homes should receive. CONCLUSION: The 3 approaches, and how they were typified as working, provide a rich picture of the stakeholder perspectives and the underlying assumptions about how service delivery models should work with care homes. The findings inform how evidence on effective working in care homes will be interrogated to identify how different approaches, or specifically key elements of those approaches, achieve different health-related outcomes in different situations for residents and associated health and social care organizations. Copyright © 2015 AMD

A Bipartisan Rx for Patient-Centered Care and System-Wide Cost Containment (US)
Bipartisan Policy Center, 2015

This paper focuses on recommendations to strengthen the quality-reporting system and the validity of available metrics. BPC encourages the present trend of private and public organizations and relevant stakeholders working together to better align the current measures and agency promulgation of a core set of measures that are clinically relevant and useful to providers, and that can be adapted to be accessible to consumers.

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Research Practice and Methodology

What affects authors’ and editors’ use of reporting guidelines? Findings from an online survey and qualitative interviews.
Non UofA Access
Fuller T, Pearson M, Peters J, Anderson R.
PloS one 2015 Apr 15;10(4):e0121585

To identify and understand, through data from multiple sources, some of the factors that affect authors’ and editors’ decisions to use reporting guidelines in the publication of health research. DESIGN: Mixed methods study comprising an online survey and semi-structured interviews with a sample of authors (online survey: n = 56; response rate = 32%; semi-structured interviews: n = 5) and journal editors (online survey: n = 43; response rate = 27%; semi-structured interviews: n = 6) involved in publishing health and medical research. Participants were recruited from an earlier study examining the effectiveness of the TREND reporting guideline. RESULTS: Four types of factors interacted to affect authors’ and editors’ likelihood of reporting guideline use; individual (e.g. having multiple reasons for use of reporting guidelines); the professional culture in which people work; environmental (e.g. policies of journals); and, practical (e.g. having time to use reporting guidelines). Having multiple reasons for using reporting guidelines was a particularly salient factor in facilitating reporting guidelines use for both groups of participants. CONCLUSIONS: Improving the completeness and consistency of reporting of research studies is critical to the integrity and synthesis of health research. The use of reporting guidelines offers one potentially efficient and effective means for achieving this, but decisions to use (or not use) reporting guidelines take many factors into account. These findings could be used to inform future studies that might, for example, test the factors that we have identified within a wider theoretical framework for understanding changes in professional practices. The use of reporting guidelines by senior professionals appears to shape the expectations of what constitutes best practice and can be assimilated into the culture of a field or discipline. Without evidence of effectiveness of reporting guidelines, and sustained, multifaceted efforts to improve reporting, little progress seems likely to be made.

Comparing the perceptions of academics and members of the public about patient and public involvement in ageing research.
Non UofA Access
Tullo ES, Robinson L, Newton J.
Age and Ageing 2014 Dec 19

Public and patient involvement (PPI) in clinical research is increasingly advocated by funding and regulatory bodies. However, little is known about the views of either academics or members of the public about perceptions of the practical realities of PPI, particularly in relation to ageing research. OBJECTIVE: to survey current levels of PPI in biomedical and clinical research relating to ageing at one institution. To compare and contrast the views of academics and the public about PPI relating to research about ageing. DESIGN: electronic survey of senior academics, postgraduate students and members of a local user group for older people. SETTING AND PARTICIPANTS: thirty-three academics (18 principal investigators and 15 PhD students) at a biomedical research institution. Fifty-four members of a local user group for older people. RESULTS: thirty per cent (10/33) of projects described some PPI activity. Older adults were more positive about active involvement in research about ageing than academics. The perceived benefits of and barriers to involvement in research were similar among all groups, although older members of the public were more likely than academics to acknowledge potential barriers to involvement. CONCLUSION: academics and older people share some perceptions about PPI in ageing research, but members of the public are more optimistic about active involvement. Further correspondence between these groups may help to identify feasible involvement activities for older people and encourage collaborative research about ageing. © The Author 2014

Change Score or Followup Score? An Empirical Evaluation of the Impact of Choice of Mean Difference Estimates
AHRQ, 2015

In randomized controlled clinical trials, continuous outcomes are typically measured at both baseline and followup time points, and mean difference is analyzed as the effect measure. There are multiple ways to estimate the mean difference: using the change score from the baseline, using the followup scores, or estimating the mean difference using the analysis of covariance (ANCOVA) model. Use of the ANCOVA model is generally preferable to using the change scores from the baseline or using the followup scores. When the baseline scores are imbalanced, using either the change score from the baseline or the followup scores would produce biased effect estimates of mean difference, while the ANCOVA model provides the least biased estimates. Nonetheless, individual studies often report results incompletely, and investigators have to summarize results across studies that are not optimally reported. The impact of using the change versus the followup score on meta-analysis has not been well studied.

Going the Extra Mile: improving the nation’s health and wellbeing through public involvement in research. (UK)
National Institute for Health Research (NIHR), 2015

This National Institute for Health Research (NIHR) report on encouraging public involvement in research recommends a strategic approach to engaging the public in goal-setting for research and research design. It is based on the “Breaking Boundaries” Strategic Review of Public Involvement in the NIHR.

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“Make Me Feel at Ease and at Home”: Differential Care Preferences of Nursing Home Residents
Non UofA Access
Bangerter LR, Van Haitsma K, Heid AR, Abbott K.
The Gerontologist 2015 04/15

Assessing and honoring older adults’ preferences is a fundamental step in providing person-centered care in long-term care facilities. Researchers and practitioners have begun to develop measures to assess nursing home (NH) residents’ everyday preferences. However, little is known about how residents interpret and conceptualize their preferences and what specific clinical response may be needed to balance health and safety concerns with preferences. Design and Methods: We used content analysis to examine interview responses on a subset of eight open-ended items from the Preferences of Every-day Living Inventory for Nursing Home (PELI-NH) residents with 337 NH residents (mean age 81). We considered how residents self-define various preferences of care and the associated importance of these preferences. Results: Residents identified preferences for interpersonal interactions (greetings, staff showing care, and staff showing respect), coping strategies, personal care (bathroom needs, setting up bedding), and healthcare discussions. Respondents highlighted specific qualities and characteristics about care interactions that are necessary to fully meeting their everyday preferences. Implications: Results contribute to an emergent body of research that utilizes patient preferences to achieve the goals of person-centered care. The complexity of these responses substantiates the use of qualitative inquiry to thoroughly assess and integrate NH resident preferences into the delivery of person-centered care.

Incontinence care in nursing homes: a cross-sectional study
Non UofA Access
Mandl M, Halfens RJ, Lohrmann C.
Journal of advanced nursing 2015 Apr 20

To describe the quality of incontinence care in nursing homes. Main outcome measures were: (1) availability of structural quality indicators on ward and institutional levels; (2) use of nursing interventions as quality indicators on a process level; (3) prevalence of incontinence as an outcome indicator. BACKGROUND: Incontinence in older people is a major problem in nursing care that presents a high workload for nurses, increases costs and places a high burden on affected individuals. The availability of structural indicators, and the use of nursing interventions, is recommended to improve the quality of care. Only limited amounts of reliable and valid data are available regarding the quality of incontinence care in nursing homes. DESIGN: A cross-sectional multicentre study in 16 nursing homes (N = 1302) in 2013. METHODS: A standardized and validated questionnaire was used for data collection. Each resident was assessed by two trained nurses. RESULTS/FINDINGS: The primary outcome of the study indicated that structural indicators, such as the availability of information brochures, are limited in nursing homes. On a process level, the provision of body worn pads or underlay pads to protect beds or chairs were most frequently used and training interventions were only delivered to a small proportion of residents with incontinence. The prevalence of all types of incontinence, particularly double incontinence, was high (69·2%). CONCLUSION: Due to the high prevalence of double incontinence and low rate of training interventions regarding this type of incontinence, ongoing efforts to improve the quality of incontinence care are warranted. © 2015 John Wiley & Sons Ltd.

Multiple perspectives on quality of life for residents with dementia in long term care facilities: protocol for a comprehensive Australian study.
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Beattie E, O’Reilly M, Moyle W, Chenoweth L, Fetherstonhaugh D, Horner B, et al.
International psychogeriatrics 2015 Apr 22:1-9

Dementia is a chronic illness without cure or effective treatment, which results in declining mental and physical function and assistance from others to manage activities of daily living. Many people with dementia live in long term care facilities, yet research into their quality of life (QoL) was rare until the last decade. Previous studies failed to incorporate important variables related to the facility and care provision or to look closely at the daily lives of residents. This paper presents a protocol for a comprehensive, multi-perspective assessment of QoL of residents with dementia living in long term care in Australia. A secondary aim is investigating the effectiveness of self-report instruments for measuring QoL. METHODS: The study utilizes a descriptive, mixed methods design to examine how facility, care staff, and resident factors impact QoL. Over 500 residents with dementia from a stratified, random sample of 53 facilities are being recruited. A sub-sample of 12 residents is also taking part in qualitative interviews and observations. CONCLUSIONS: This national study will provide a broad understanding of factors underlying QoL for residents with dementia in long term care. The present study uses a similar methodology to the US-based Collaborative Studies of Long Term Care (CS-LTC) Dementia Care Study, applying it to the Australian setting.

Nursing home resident quality of life: testing for measurement equivalence across resident, family, and staff perspectives.
Non UofA Access
Godin J, Keefe J, Kelloway EK, Hirdes JP.
Quality of life research 2015 Apr 17

This study explores the factor structure of the interRAI self-report nursing home quality of life survey and develops a measure that will allow researchers to compare predictors of quality of life (QOL) across resident, family, and staff perspectives. METHODS: Nursing home residents (N = 319), family members (N = 397), and staff (N = 862) were surveyed about their perceptions of resident QOL. Exploratory factor analyses were conducted on a random half of the staff data. Subsequently, confirmatory factor analysis was used to test for measurement equivalence across the three perspectives. RESULTS: The final model had a four-factor structure (i.e., care and support, food, autonomy, and activities) across all three perspectives. Each factor had at least two items that were equivalent across all three perspectives, which suggests at least partial measurement equivalence. CONCLUSION: The finding of partial measurement equivalence acknowledges there are important differences between perspectives and provides a tool that researchers can use to compare predictors of QOL, but not levels of agreement across perspectives. Targeting these four aspects is likely to have the additional benefit of improving family and staff perceptions of resident QOL in addition to the resident’s own QOL.

Sex Differences in Home Care Performance: A Population-Based Study.
Non UofA Access
Lo AT, Gruneir A, Bronskill SE, Bierman AS.
Women’s health issues 2015 Apr 9

Home care services play an integral role in promoting independence, reducing hospital admission and readmission rates, and preventing or delaying nursing home admission among older adults. Despite important sex differences in functional status and use of services by recipients of home care, differences in home care performance measures by sex have not been examined. OBJECTIVE: To assess sex differences in the quality of publicly funded home care services in Ontario, Canada. METHODS: Validated, publicly reported home care quality indicators derived from the Resident Assessment Instrument for Home Care using the 2009 and 2010 Home Care Reporting System database were assessed for 119,795 Ontario home care clients aged 65 years and older. Unadjusted and risk-adjusted sex differences in performance were examined provincially and by health region. RESULTS: In unadjusted analyses, there were sex differences in health outcomes on all indicators examined (decline or failure to improve in activities of daily living, cognitive decline, depressive symptoms, and pain control). After risk adjustment, differences were minimal. For example, in unadjusted analyses, 23.1% of women and 18.7% of men reported poorly controlled pain. After risk adjustment, 21.2% of women and 21.6% of men reported poorly controlled pain, with a difference of -0.4% (95% CI, -0.4% to -0.3%). Across health regions risk adjustment eliminated sex differences. There was 1.3-fold to 2.6-fold variation in performance on indicators across health regions. CONCLUSIONS: After risk adjustment, no important sex differences in home care quality indicators were identified. Sizable regional variations observed indicate potential to improve home care outcomes for both women and men. Sex differences in unadjusted analyses demonstrate the value of examining both unadjusted and adjusted outcomes and suggest sex-specific strategies will likely be needed to improve home care quality. Copyright © 2015 Jacobs Institute of Women’s Health.

Effect of therapeutic massage on pain in patients with dementia
Non UofA Access
Kapoor Y, Orr R.
Dementia 2015 04/23

The aim was to investigate whether therapeutic massage was effective in relieving pain in elderly residents with dementia. Methods A randomized controlled study was conducted in an aged care facility. Ten participants with dementia or advanced dementia were allocated to an intervention group or a control group. The intervention group received 10 min of massage (effleurage, kneading, and trigger point therapy) four times per week for 4 weeks. The Pain Assessment in Advanced Dementia scale was used as the outcome measure. Results No significant changes in mean outcome measure scores were found post intervention (Intervention mean = 5.0 ± 3.49; Control mean = 5.2 ± 3.49: t(8) = 0.09, p = 0.93). However, the Intervention Group had a greater magnitude of change (1.200 ± 1.78) when compared to the control group (0.800 ± 2.16). Conclusion Therapeutic massage may provide a useful adjunct to the current pain management plan of patients with dementia.

Dual Sensory Impairment and Cognitive Decline: The Results From the Shelter Study.
Non UofA Access
Yamada Y, Denkinger MD, Onder G, Henrard JC, van der Roest HG, Finne-Soveri H, et al.
The journals of gerontology.Series A, Biological sciences and medical sciences 2015 Apr 13

To examine whether nursing home residents with concurrent vision and hearing impairment, dual sensory impairment (DSI), have a greater cognitive decline over time than do those without sensory impairment and whether social engagement modifies this association. Methods: Based on the Services and Health for Elderly in Long TERm Care study, 1,989 nursing home residents who were assessed using the interRAI LTCF at 6-month intervals over 1 year were included. Multivariate linear regression models with time-variant exposure variables of sensory impairment and social engagement using generalized estimating equations were performed to predict cognitive function measured by the Cognitive Performance Scale (range 0-6). Results: Residents with DSI had a greater cognitive decline [changes in Cognitive Performance Scale over 1 year = 1.12 (95% confidence interval = 0.81:1.42)] compared to those with either vision or hearing impairment [0.67 (0.53:0.64)] and those without sensory impairment [0.56 (0.48:0.64)]. A lower level of social engagement was also associated with a greater cognitive decline. The combined exposure variable of sensory impairment and social engagement revealed the greatest cognitive decline for socially disengaged residents with DSI [1.87 (1.24:2.51)] and the potential effect modification of social engagement on the association between DSI and cognitive decline; DSI was not associated with a greater cognitive decline among socially engaged residents, while it was associated among socially disengaged residents DISCUSSION : Cognitive function declines faster in nursing home residents with DSI only when residents were not socially engaged. Therefore, residents with DSI might cognitively benefit from interventions to improve involvement in social life at nursing homes. © The Author 2015.

Influencers on quality of life as reported by people living with dementia in long-term care: a descriptive exploratory approach.
Non UofA Access
Moyle W, Fetherstonhaugh D, Greben M, Beattie E, AusQoL group.
BMC geriatrics 2015 Apr 23;15(1):50

Over half of the residents in long-term care have a diagnosis of dementia. Maintaining quality of life is important, as there is no cure for dementia. Quality of life may be used as a benchmark for caregiving, and can help to enhance respect for the person with dementia and to improve care provision. The purpose of this study was to describe quality of life as reported by people living with dementia in long-term care in terms of the influencers of, as well as the strategies needed, to improve quality of life. METHODS: A descriptive exploratory approach. A subsample of twelve residents across two Australian states from a national quantitative study on quality of life was interviewed. Data were analysed thematically from a realist perspective. The approach to the thematic analysis was inductive and data-driven. RESULTS: Three themes emerged in relation to influencers and strategies related to quality of life: (a) maintaining independence, (b) having something to do, and (c) the importance of social interaction. CONCLUSIONS: The findings highlight the importance of understanding individual resident needs and consideration of the complexity of living in large group living situations, in particular in regard to resident decision-making.

Association between pain, neuropsychiatric symptoms, and physical function in dementia: a systematic review and meta-analysis
van Dalen-Kok A,H., Pieper MJC, de Waal M,W.M., Lukas A, Husebo BS, Achterberg WP.
BMC Geriatrics 2015 04;15(1):49

Pain, neuropsychiatric symptoms (NPS) and functional impairment are prevalent in patients with dementia and pain is hypothesized to be causal in both neuropsychiatric symptoms (NPS) and functional impairment. As the exact nature of the associations is unknown, this review examines the strength of associations between pain and NPS, and pain and physical function in patients with dementia. Special attention is paid to the description of measurement instruments and the methods used to detect pain, NPS and physical function. Methods A systematic search was made in the databases of PubMed (Medline), Embase, Cochrane, Cinahl, PsychINFO, and Web of Science. Studies were included that described associations between pain and NPS and/or physical function in patients with moderate to severe dementia. Results The search yielded 22 articles describing 18 studies, including two longitudinal studies. Most evidence was found for the association between pain and depression, followed by the association between pain and agitation/aggression. The longitudinal studies reported no direct effects between pain and NPS but some indirect effects, e.g. pain through depression. Although some association was established between pain and NPS, and pain and physical function, the strength of associations was relatively weak. Interestingly, only three studies used an observer rating scale for pain-related behaviour. Conclusions Available evidence does not support strong associations between pain, NPS and physical function. This might be due to inadequate use or lack of rating scales to detect pain-related behaviour. These results show that the relationship between pain and NPS, as well as with physical function, is complicated and warrants additional longitudinal evaluation.

Efficacy and safety of atypical antipsychotic drug treatment for dementia: a systematic review and meta-analysis.
Non UofA Access
Tan L, Tan L, Wang HF, Wang J, Tan CC, Tan MS, et al.
Alzheimer’s research & therapy 2015 Apr 20;7(1):20-015-0102-9. eCollection 2015

A wide variety of atypical antipsychotic drugs (risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone and clozapine) are widely used in the management of neuropsychiatric symptoms, which are commonly seen in dementia, but results from randomised controlled trials (RCTs) on the efficacy and safety of these agents are conflicting. We aimed to quantify the efficacy and safety of atypical antipsychotic drugs on neuropsychiatric symptoms in dementia patients. METHODS: PubMed, EMBASE, the Cochrane Controlled Trials Register and the Cochrane Database of Systematic Reviews for reports published before August 2014 were searched for eligible randomized controlled trials of atypical antipsychotic drugs therapy in patients with psychotic symptoms of dementia. Two reviewers independently assessed the quality of the trials and extracted information. RESULTS: Overall, 23 relevant RCTs with 5,819 participants were identified. This meta-analysis demonstrated a significant efficacy of atypical antipsychotics on psychiatric symptoms and cognitive functions compared to placebo. In the meta-analysis, the weighted mean differences (WMDs) in change scores for psychiatric symptoms were in favor of aripiprazole (-4.4, 95% confidence interval (CI) – 7.04 to -1.77) and risperidone (-1.48, 95% CI -2.35 to -0.61) compared to placebo. In cognitive effects, WMDs in change scores for the Clinical Global Impression-Change (CGI-C) were in favor of aripiprazole, risperidone, olanzapine and quetiapine which ranged from a -0.30 points mean difference (95% CI:-0.59 to -0.01) in the aripiprazole trials to -0.43 (95% CI:-0.62 to -0.25) in the risperidone group. Patients receiving atypical antipsychotics showed no difference in risk for injuries or falls (P > 0.05), significantly higher risks (P < 0.05) for somnolence, urinary tract infection, edema and abnormal gait. However, there was no significant evidence for death reported. CONCLUSION: Aripiprazole and risperidone are able to improve psychiatric symptoms and slow decline in cognition function at average 12 weeks in patients with neuropsychiatric symptoms of dementia. However, high adverse events may offset the efficacy of atypical antipsychotics in dementia.

Living Alone and Patient Care Experiences: The Role of Gender in a National Sample of Medicare Beneficiaries.
Non UofA Access
Beckett MK, Elliott MN, Haviland AM, Burkhart Q, Gaillot S, Montfort D, et al.
The journals of gerontology.Series A, Biological sciences and medical sciences 2015 Apr 13

Seniors who live alone are a large, growing population with poorer health outcomes. We examine the little-studied health care experiences and immunizations of older adults who live alone. METHODS: We use regression-based case-mix adjustment to compare immunizations and health care experiences of 325,649 adults aged 65 and older who lived alone to those who did not, overall and by gender and health status, using nationally representative data from the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) surveys. Outcomes were five global care ratings (health plan, drug plan, doctor, specialists, all care), six composite care measures (getting needed care, getting care quickly, doctor communication, customer service, getting needed drugs, getting information from drug plan), and two immunization measures (influenza, pneumonia). RESULTS: About 30.3% of respondents lived alone. Women, older beneficiaries, and low income (Medicaid eligible) beneficiaries reported living alone at substantially higher rates than their counterparts. Care experiences for 8 of the 13 measures were significantly worse for those who lived alone than for others. The association differed significantly in magnitude by gender for 10 measures, with larger average differences for men. The largest disadvantages for those living alone were for immunization measures (eg, influenza -6 percentage points, for men living alone vs other men). The disadvantages of living alone were not consistently greater for those in worse health. CONCLUSIONS: Living alone is associated with worse care experiences and immunization, especially for men. Health plans should target quality improvement and outreach efforts to beneficiaries who live alone, especially men. © The Author 2015.

Resident-to-resident physical aggression leading to injury in nursing homes: a systematic review
Non UofA Access
Ferrah N, Murphy BJ, Ibrahim JE, Bugeja LC, Winbolt M, LoGiudice D, et al.
Age and Ageing 2015 Jan 28

Resident-to-resident aggression (RRA) is an understudied form of elder abuse in nursing homes. OBJECTIVE: the purpose of this systematic review was to examine the published research on the frequency, nature, contributing factors and outcomes of RRA in nursing homes. METHODS: in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, this review examined all original, peer-reviewed research published in English, French, German, Italian or Spanish between 1st January 1949 and 31st December 2013 describing incidents of RRA in nursing homes. The following information was extracted for analysis: study and population characteristics; main findings (including prevalence, predisposing factors, triggers, nature of incidents, outcomes and interventions). RESULTS: eighteen studies were identified, 12 quantitative and 6 qualitative. The frequency of RRA ranged from 1 to 122 incidents, with insufficient information across the studies to calculate prevalence. RRA commonly occurred between exhibitors with higher levels of cognitive awareness and physical functionality and a history of aggressive behaviours, and female targets who were cognitively impaired with a history of behavioural issues including wandering. RRA most commonly took place in the afternoon in communal settings, was often triggered by communication issues and invasion of space, or was unprovoked. Limited information exists on organisational factors contributing to RRA and the outcomes for targets of aggression. CONCLUSIONS: we must continue to grow our knowledge base on the nature and circumstances of RRA to prevent harm to an increasing vulnerable population of nursing home residents and ensure a safe working environment for staff. © The Author 2015.

A longitudinal cohort study evaluating the impact of a geriatrician-led residential care outreach service on acute healthcare utilisation.
Non UofA Access
Hutchinson AF, Parikh S, Tacey M, Harvey PA, Lim WK.
Age and Ageing 2014 Dec 23

Over the last decade, high demand for acute healthcare services by long-term residents of residential care facilities (RCFs) has stimulated interest in exploring alternative models of care. The Residential Care Intervention Program in the Elderly (RECIPE) service provides expert outreach services to RCFs residents, interventions include comprehensive care planning, management of inter-current illness and rapid access to acute care substitution services. OBJECTIVE: to evaluate whether the RECIPE service decreased acute healthcare utilisation. DESIGN: a retrospective cohort study using interrupted time series analysis to analyse change in acute healthcare utilisation before and after enrolment. SETTING: a 300-bed metropolitan teaching hospital in Australia and 73 RCFs within its catchment. SUBJECTS: there were 1,327 patients enrolled in the service with a median age of 84 years; 61% were female. METHODS: data were collected prospectively on all enrolled patients from 2004 to 2011 and linked to the acute health service administrative data set. Primary outcomes change in admission rates, length of stay and bed days per quarter. RESULTS: in the 2 years prior to enrolment, the mean number of acute care admissions per patient per year was 3.03 (SD 2.9) versus post 2.4 (SD 3.3), the service reducing admissions by 0.13 admissions per patient per quarter (P = 0.046). Prior to enrolment, the mean length of stay was 8.6 (SD 11.0) versus post 3.5 (SD 5.0), a reduction of 1.5 days per patient per quarter (P = 0.003). CONCLUSIONS: this study suggests that an outreach service comprising a geriatrician-led multidisciplinary team can reduce acute hospital utilisation rates. © The Author 2014.

Cognitive impairment, all-cause and cause-specific mortality among non-demented older adults.
Non UofA Access
Perna L, Wahl HW, Mons U, Saum KU, Holleczek B, Brenner H.
Age and Ageing 2014 Dec 2

Cognitive impairment is widespread among older adults even in the absence of dementia, but very little is known about the association between cognitive impairment not due or not yet converted to dementia and mortality. The association between cognitive impairment and mortality contributes to assessing cognitive impairment-related risk constellation in old age in the absence of manifest dementia. OBJECTIVE: to assess the impact of cognitive impairment on all-cause and cause-specific mortality among non-demented older adults and to explore the nature of the association between cognitive impairment and mortality. DESIGN: an observational cohort study (ESTHER study; 2000-present). SETTING: German state of Saarland. SUBJECTS:: a subsample of 1,622 participants aged ≥70 with measurement of cognitive function through the Cognitive Telephone Screening Instrument (COGTEL) and exclusion of a possible dementia diagnosis at both COGTEL baseline (2005-08) and over the mortality follow-up (2005-13). RESULTS: during an average follow-up of 6.1 years, 231 participants (14.2%) died. Participants with low COGTEL total scores had ∼60% increased mortality compared with participants with higher COGTEL total scores in Cox regression models adjusting for a wide range of possible confounders (hazard ratio = 1.62; confidence interval 1.13-2.33). Dose-response analyses with restricted cubic splines indicate a monotonic inverse relationship between cognitive function and mortality. CONCLUSION: cognitive impairment in the absence of manifest dementia is an important independent predictor of mortality, especially among men. The administration of cognitive tests among older adults may provide relevant information for patient care and treatment decisions. SOURCES OF FUNDING: financial sponsors played no role in the design, execution, analysis and interpretation of data. © The Author 2014.

Measuring frailty using self-report and test-based health measures. Canada-flat-icon
Non UofA Access
Theou O, O’Connell MD, King-Kallimanis BL, O’Halloran AM, Rockwood K, Kenny RA.
Age and Ageing 2015 Feb 16

Previously, frailty indices were constructed using mostly subjective health measures. The reporting error in this type of measure can have implications on the robustness of frailty findings. OBJECTIVE: to examine whether frailty assessment differs when we construct frailty indices using solely self-reported or test-based health measures. DESIGN: secondary analysis of data from The Irish LongituDinal study on Ageing (TILDA). SUBJECTS AND METHODS: 4,961 Irish residents (mean age: 61.9 ± 8.4; 54.2% women) over the age of 50 years who underwent a health assessment were included in this analysis. We constructed three frailty indices using 33 self-reported health measures (SRFI), 33 test-based health measures (TBFI) and all 66 measures combined (CFI). The 2-year follow-up outcomes examined were all-cause mortality, disability, hospitalisation and falls. RESULTS: all three indices had a right-skewed distribution, an upper limit to frailty, a non-linear increase with age, and had a dose-response relationship with adverse outcomes. Levels of frailty were lower when self-reported items were used (SRFI: 0.12 ± 0.09; TBFI: 0.17 ± 0.15; CFI: 0.14 ± 0.13). Men had slightly higher frailty index scores than women when test-based measures were used (men: 0.17 ± 0.09; women: 0.16 ± 0.10). CFI had the strongest prediction for risk of adverse outcomes (ROC: 0.64-0.81), and age was not a significant predictor when it was included in the regression model. CONCLUSIONS: except for sex differences, characteristics of frailty are similar regardless of whether self-reported or test-based measures are used exclusively to construct a frailty index. Where available, self-reported and test-based measures should be combined when trying to identify levels of frailty. © The Author 2015.

Progress towards predicting 1-year mortality in older people living in residential long-term care.
Non UofA Access
Heppenstall CP, Broad JB, Boyd M, Gott M, Connolly MJ.
Age and Ageing 2015 Feb 3

Frail older people living in residential long-term care (LTC) have limited life expectancy. Identifying those with poor prognosis may improve management and facilitate transition to a palliative approach to care. OBJECTIVE: to develop methods for predicting mortality in LTC. DESIGN:: a population-based cohort study. SETTING:: LTC facilities, Auckland, New Zealand. SUBJECTS: five hundred randomly selected older people in a census-type survey of those living in LTC in 2008. METHODS:: mortality data were obtained from New Zealand Ministry of Health. Two methods for assessing mortality risk were developed using demographic, functional and health service information: (i) two geriatricians blinded to identifying data and to mortality, independently reviewed survey, medications and pre-survey hospitalisations data, and grouped residents according to perceived risk of death within 12 months; (ii) multivariate logistic regression model used the same survey and medication items as the geriatricians. RESULTS: for the geriatricians’ assessment, each quintile of perceived risk was associated with a significant increase in mortality (P 50%. CONCLUSION: two methods with the potential to identify older people with limited prognosis are described. Use of these methods allowed identification of over half of those who died within 12 months. © The Author 2015.

Visualising the distribution of individuals of advanced age in Canada: linking census data to maps. Canada-flat-icon
Non UofA Access
Romanski J, Wu W, Anderson PJ, Austin PC, Rochon PA.
Age and Ageing 2015 Jan 19

To link publically available aggregate census data to maps to visually convey information about the geographic distribution of those of advanced age in Canada. METHOD: we obtained aggregate statistics derived from the most recent 2011 Canadian census data. We calculated the Percentage of People 90 Years of Age or Older and the Longevity Index in each of the 292 census divisions. The data and the Canadian census division map were merged to create thematic maps using Google Fusion Tables. RESULTS: overall, there were 217,930 women and men who were 90 years of age or older in Canada in 2011. The regions with the highest proportion of elderly residents are in the south, rather than in the north of Canada. Southern Saskatchewan and southern Manitoba emerged as high longevity areas based on both indices. CONCLUSIONS: publically available data and free online tools can be used to create maps that visually display the geographic distribution of the oldest population across Canada. This approach provides an efficient way to observe patterns, identify adjacencies and perceive information that may not have been anticipated. This approach can be replicated in other jurisdictions using publically available data. © The Author 2015.

Factors that impact residents’ transition and psychological adjustment to long-term aged care: A systematic literature review
Non UofA Access
Brownie S, Horstmanshof L, Garbutt R.
International journal of nursing studies 2014 Dec;51(12):1654-1666

To identify the factors that impact residents’ transition and adjustment to long-term aged care and influence their relocation experience. BACKGROUND: The transition to long-term aged care can be an emotional and stressful event for older people as well as their families and carers. The challenges triggered by relocation derive from home being on the move. The concept of home and Bridges’ three stages of transition framework provide conceptual models for better understanding the needs and aspiration of older people who are in the process of this late life transition. METHOD: We searched Academic Search Premier, Cinahl, Medline, PyscINFO, Psychology and Behavioral Sciences Collection and Scopus databases for observational, descriptive studies published between January 1995 and July 2013 using subject headings and free-text search terms including adjustment, nursing homes, relocation and transition. RESULTS AND DISCUSSION: The search identified 348 potentially relevant articles. Once duplicates were removed, 214 articles were screened for inclusion in this review; 42 articles were assessed for eligibility, resulting in 19 high-quality observational, descriptive studies that met the inclusion criteria. Key determinants of residents’ relocation experience include the extent to which they were able to exert control over the decision to move to an aged care facility, preserve their autonomy, and retain meaningful social relationships. Encouraging the development of new relationships with other residents and staff is an important role for staff to play. Providing residents with opportunities to talk about their feelings, their life experience, and their involvement in the decision to relocate to an aged care facility can help them in their transition to an aged care facility. Preadmission screening that provides staff with an understanding of personal, lifestyle and cultural needs that might facilitate improved transition may also be beneficial in care planning. CONCLUSION AND IMPLICATIONS: An understanding of the factors that impact residents’ transition to long-term aged care, and their experience of relocation will assist aged care providers to create the conditions to ease adjustment anxiety and to facilitate a person’s transition into his/her ‘last home’. Copyright © 2014 Elsevier Ltd.

Introducing an Equal Rights Framework for Older Persons in Residential Care
Non UofA Access
Jönson H, Harnett T.
The Gerontologist 2015 04/22

This article reconceptualizes residential care for older persons by introducing a framework developed from a rights-based principle of disability policies: the normalization principle. This principle is part of the social model and states that society should make available for people who have impairments living conditions that are as close as possible to those of “others.” Using the framework on the case of eldercare in Sweden shows that although disability policies have used people without impairments as a comparative (external) reference group for claiming rights, eldercare policies use internal reference groups, basing comparisons on other care users. The article highlights the need for external comparisons in eldercare and suggests that the third age, which so far has been a normative reference group for older people, could be a comparative reference group when older persons in need of care claim rights to equal conditions.

The Very Elderly Admitted to ICU: A Quality Finish? Canada-flat-icon
Non UofA Access
Heyland D, Cook D, Bagshaw SM, Garland A, Stelfox HT, Mehta S, et al.
Critical care medicine 2015 Apr 21

Very elderly persons admitted to ICUs are at high risk of death. To document life-sustaining interventions (mechanical ventilation, vasopressors, renal replacement therapy) provided in the ICU and outcomes of care. DESIGN: Multicenter, prospective cohort study. SETTING: ICUs of 24 Canadian hospitals. PARTICIPANTS/SETTING: Patients 80 years old or older admitted to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One thousand six hundred seventy-one patients were included. The average age of the cohort was 85 years (range, 80-100 yr). Median total length of stay in ICU was 4 days (interquartile range, 2-8 d) and in hospital was 17 days (interquartile range, 8-33 d). Of all patients included, 502 (30%) stayed in ICU for 7 days or more and 344 (21%) received some form of life-sustaining treatment for at least 7 days. ICU and hospital mortality were 22% and 35%, respectively. For nonsurvivors, the median time from ICU admission to death was 10 days (interquartile range, 3-20 d). Of those who died (n = 5 85), 289 (49%) died while receiving mechanical ventilation, vasopressors, or dialysis. The presence of frailty or advance directives had little impact on limiting use of life-sustaining treatments or shortening the time from admission to death. CONCLUSIONS: In this multicenter study, one third of very elderly ICU patients died in hospital, many after a prolonged ICU stay while continuing to receive aggressive life-sustaining interventions. These findings raise questions about the use of critical care at the end of life for the very elderly.

Gauging Aging: Mapping the Gaps between Expert and Public Understanding of Aging in America
Frameworks Institute, 2015

A new report from an eight-member expert collaborative, Leaders of Aging Organizations (LAO), and the FrameWorks Institute proposes to reclaim the social narrative on what aging really means by building better perceptual connections between health care experts, advocates, and the thousands of Americans who turn 65 every day.

Understanding Health and Social Services for Seniors in Canada Canada-flat-icon
Conference Board of Canada

This report provides a uniquely comprehensive overview of seniors care in Canada in 2015 that can inform the design of future programs, plans, and strategies to better address seniors’ needs. It presents the social and economic context of seniors’ health in Canada; notes measures that are being or can be implemented to help individuals remain independent for as long as possible; looks at the services currently available; and explores challenges to seniors care programs. Finally, the report presents good practices and emerging approaches, from both Canada and other countries, that are improving the provision of and satisfaction with seniors care among clients and their families.

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Save the Date: The De Hogeweyk Dementia Care Revolution
Thursday 22 October 07:00-09:00 Edmonton Expo Centre at Northlands

It has been said that if the current price tag for dementia care were the economy of a country, it would be the 15th or 16th largest economy in the world! Around the globe, the world’s population is aging – and a new case of dementia occurs every four seconds. The disease places a crippling strain on families and the challenge is about to get worse. In Holland, adults with severe dementia can live in a specially designed self‐contained “Dementia Village” called De Hogeweyk, where residents can maintain their sense of independence while receiving the specialized care they need. Delegates from many countries have visited the village and this design and approach to care for those with dementia could become the gold standard as a cost‐effective and humane response to an aging population. Join the Glenrose Rehabilitation Hospital as we learn about best practices in Dementia Care from our international colleague Mr. Eloy van Hal, graduate of Wageningen University and Facility Manager at De Hogeweyk.

Non UofA

Save the Date: 2016 World interRAI Conference
11-14 April 2016 Toronto

The 1st World interRAI Conference provides an important forum that brings together researchers, policy makers and practitioners from around the globe, using the interRAI system of instruments in community and home care, residential/long-term care, acute care, assisted living, mental health and palliative care. These evidence-based electronic instruments capture client/patient assessment information that is used to support care planning and delivery, quality improvement, health system management and policy development.

2nd Annual Clinical Health Research Conference
Alberta Clinical Research Consortia
Wednesday 17th June Calgary AB $50

Join other study coordinators, administrators and investigators as we focus on hot topics and current challenges in clinical health research.
5 Reasons to Attend
1. Be inspired – Walk away with a new perspective after hearing firsthand experiences from a clinical trial participant.
2. Stay informed – Find out about the latest changes to the 2nd edition of the Tri-Council Policy Statement (TCPS2) and the implications for REB submission and study conduct.
3. Customize your learning – Choose from many topics in clinical health research and learn about best practices to implement at your site.
4. Network with others and gain insights from your peers.
5. Find out what’s happening behind the scenes to optimize clinical health research in Alberta.


KT Canada: Understanding how parents of children with autism navigate complex information and care
Health Decision Making with Aboriginal Women: A qualitative study exploring needs, supports and barriers

Thursday 14 May 10:00-11:00 MT Will be shown in ECHA 4-099
Presenters Stephen Gentles & Janet Jull

Learning Objectives:
-Understand how informal caregivers in complex informational contexts navigate-and participate in care
-Understand the utility of qualitative research for developing local theory that is highly relevant to specific settings
-Appreciate the relevance of health care consumer-centered qualitative research-for improving patient-centered care
Learning Objectives:
-Describe a needs assessment conducted using qualitative research methods
-Describe a collaborative research study
-Introduce concepts of culturally appropriate shared decision making in a framework developed by and with an Aboriginal population

CFHI Webinar The Chronic Care Model: Designing Care with ‘Chronic’ as the New Norm
Friday 8 May 10:00-11:00 MT

Join leading chronic care expert, Dr. Edward Wagner, Director (Emeritus), MacColl Center, as he discusses the evolution of the Chronic Care Model, now simply known as the Care Model, and its continuing role in helping establish good chronic illness care. Dr. Wagner will explore the elements of the Care Model that are important for enhancing chronic care for both patients and providers, including whole-person knowledge of patients, productive and meaningful relationships with specialists, and clear accountability for the totality of care.

KT Canada Twitter Journal Club
Thursday 21 May 10:00-11:00 MT

What is Twitter Journal Club? The purpose of this activity is to advance knowledge of relevant literature in the area of implementation science. The presentations focus on appraisal of the validity and importance of the article and then to place it in context with other literature. Sessions will be held by Webex and be followed by 24 hours of tweeting using: #KTCJClub.The articles are From best evidence to best practice: effective implementation of change in patients’ care and Growing Literature, Stagnant Science? Systematic Review, MetaRegression and Cumulative Analysis of Audit and Feedback Interventions in Health Care. Interested participants should email Meghan Storey to register.

American Institutes for Research Webinar: Survey Planning and Administration
Tuesday June 2 13:00-14:00 MT

Survey Planning and Administration is the second in a planned series of webinars for state vocational rehabilitation personnel by American Institutes for Research (AIR), a not-for-profit organization engaged in research, development, evaluation, and analysis in the behavioral and social sciences. To register, please e-mail
Topics to be discussed:
Planning for a Survey (12 minutes)
Designing Survey Questions (12 minutes)
Data Collection Methods (18 minutes)
Hard-to-reach populations
Response rates (6 minutes)
An analysis plan (12 minutes)
After completing the webinar, participants will be able to:
Identify situations where surveys are and are not an appropriate way to gather the information desired
Describe how surveys can provide data useful for evaluating the success of vocational rehabilitation programs
Understand the main principles of survey question design
Describe the options available for collecting data
Describe and calculate survey response rates
Understand the principles of analyzing survey data

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Ombudsman reviewing 79 complaints about seniors care in Saskatchewan Canada-flat-icon

Saskatchewan’s ombudsman says she has received 79 complaints about various nursing homes and her recommendations on seniors care will apply to the entire province.

W5 nursing home investigation reveals 1,500 cases of staff-to-resident abuse in a year Canada-flat-icon

Over the course of a one year investigation, W5 uncovered at least 1,500 cases of staff-to-resident abuse and neglect in nursing homes across Canada in 2013. That number is likely higher due to under-reporting of incidents.

Minister Ambrose Hosts Healthy Aging Roundtable Canada-flat-icon

The roundtable was attended by a variety of seniors- and health-related organizations and was an opportunity to hear their perspectives and ideas on healthy aging related issues such as dementia, injury prevention, mental health and age-friendly communities.

CIHR A Pan-Canadian Vision and Strategy for Health Services and Policy Research Canada-flat-icon

To position Canada as a global leader in health services and policy research that optimizes health and health system outcomes, the CIHR Institute of Health Services and Policy Research (CIHR-IHSPR), provincial health research funding organizations, and many of Canada’s health charities partnered with the community to develop the first-ever pan-Canadian vision and strategy for health services and policy research (HSPR). The results of the first year of collaboration are complete and available in a comprehensive report, complementary asset map and Pan-Canadian Vision and Strategy for Health Services and Policy Research.

INANE: Announcing the Nursing Editors History Project

The Nursing Editors History Project is an initiative to:
-Document the history of editorial leadership in nursing from 1900 to the present.
-Identify the people and organizations that have influenced the development of modern nursing practice and nursing knowledge..
-Preserve stories provided by informants that relate to editorial leadership in nursing publications.
-Provide a database that can be accessed, searched, and used by a variety of scholars to who seek to understand the important role of editorial leadership.
If you have information about any nursing journal, past or present, we want to hear from you! Find out more about this project in the “About” Section of this site, and share your information using the online Submission Form.

10 things you need to know before you peer review

Here are the top 10 things you need to know when doing peer review.

Why Many Doctors Don’t Follow ‘Best Practices’ (US)

Even in the midst of good science and a clear consensus on what should be done, a lot of physicians don’t follow the “best practice” guidelines.

UBC study finds ‘nurse navigators’ play vital role in senior care Canada-flat-icon

Retirement can be a big adjustment for someone who has spent his or her whole life working and keeping busy. Many of these newly retired professionals want to keep contributing to their community but aren’t sure how. A three-year study conducted by researchers at UBC Okanagan may give them some ideas. The study shows these baby boomers can help seniors with chronic illnesses live independent lives.

Building Better Nursing Homes (US)

After plenty of isolated successes, the question isn’t what good nursing homes look like, but how to transform existing facilities into places that look like them.

Process designed to take stress out of moving into long-term care Canada-flat-icon

Making the decision to move into a long-term care (LTC) home can be a difficult thing to do for both the individual involved and his or her family. Because of that, moving in should be as smooth and stress-free as possible, and that’s what a group of staff from Saskatoon Health Region is working on achieving during 90 Days of Innovation: Ready Every Day, which has improving the patient experience as one of its goals.

Long-term care cuts will help save Nova Scotia $3.6m Canada-flat-icon

There is half as much money in this year’s provincial budget for long-term care homes to purchase small equipment, and 103 of the 143 facilities are not getting cost of living increases.

Nursing Homes Are Starting to Supplant Hospitals as Focus of Basic Health Care (US)

The notion that a hospital remains the safest place for old patients dies hard. Many families still believe their aging relatives belong in a hospital when they’re ailing. But 20-plus years of research have documented the risks of hospitalization for older adults, particularly those frail or ill enough to need nursing home care.

Institute of Medicine to Become National Academy of Medicine (US)

National Academy of Sciences (NAS) members voted to change the name of the Institute of Medicine to the National Academy of Medicine, effective July 1, 2015.

Backgrounder: Why more healthcare is not always the answer Canada-flat-icon

Does more healthcare create better outcomes? In other words, do more medications, tests and interventions necessarily result in healthier patients? It turns out more care is, all too often, unnecessary care. For example, appropriate care would be getting antibiotics for an infection caused by bacteria. Getting antibiotics for a viral infection that is not helped by antibiotics — such as the common cold — would be unnecessary care.

Saskatchewan has the highest rates of HIV in Canada. Can we create an AIDS-free generation? Canada-flat-icon

Over the last few years, Saskatchewan has experienced alarming spikes in the number of HIV cases. In fact, in 2009, their rates were comparable to those in Nigeria and Saskatchewan continues to have the highest rates in Canada. Dr. Ryan Meili explains what happened in Saskatchewan and how British Columbia’s strategy in reducing the spread of HIV and AIDS is a model for other Canadian provinces.

Faculty in Canada may not need rules for using social media, observers say Canada-flat-icon

Peter Chow-White, an associate professor in SFU’s school of communication, said he was “not sure professors necessarily need guidelines. We publish on a regular basis; if we can write articles and books … we probably don’t need to be told how to write a 140-character tweet.

Some glimmers of hope from the granting councils Canada-flat-icon

A change to open-access policies, and NSERC’s move on parental leave, are worth celebrating.

Up to 220,000 care workers paid less than minimum wage, figures show (UK)

More than half the care companies investigated by customs officials are paying their workers less than the minimum wage, according to figures unearthed by the shadow social care minister, Liz Kendall.

What evidence do MPs turn to when they make policy? (UK)

MPs value the views of constituents and expert opinion more highly than evidence from randomised controlled trials, a new survey has found. However, the majority of the 104 Labour and Conservative MPs from the previous parliament who were questioned support the idea of using randomised controlled trials to evaluate policies and don’t believe they are too expensive.

Poor homecare training putting elderly at risk, according survey (UK)

A new survey reveals that staff are receiving inadequate homecare training putting elderly and disabled at risk.mThe survey conducted by UNISON included more than 1,000 care workers employed by councils and private firms across the UK.

‘Totally unacceptable’ for long-term care residents to pay staff for extra baths: Quebec health minister Canada-flat-icon

Quebec’s health minister says he has told orderlies at health-care facilities to stop accepting cash payments from patients wanting more than one bath per week.

5 Innovative Programs Add Quality to Life at Continuing Care Retirement Communities (US)

LeadingAge members are known for their innovative programming, whether they are finding new ways to deliver care to vulnerable older adults, helping residents maintain their health and independence, or creating out-of-the-ordinary opportunities for simply enjoying life. Here’s a roundup of news about innovations taking place at The Mercy Community, Hebrew Home at Riverdale, Felician Village, La Loma Village, and Carolina Meadows.

Abbeyfield UK: State of the art dementia care development gets underway at Winnersh

Work has started on a pioneering new Abbeyfield Society care home in Winnersh, which will provide an innovative, stimulating and exciting environment for people living with dementia.

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Dementia Peer Support Resource Pack

The Health Innovation Network worked with The Alzheimer’s Society, Innovations in Dementia and community groups across South London to produce a Resource Pack to promote the importance of peer support opportunities for people with dementia. It brings together in one place evidenced based resources to help community groups and funders set up and run peer support groups, as well as guidance on how to make older people groups more dementia friendly. It includes films, case studies, policy and research related to the benefits of peer support, as well as resources on funding, staff training and evaluation of groups. It has been developed for the statutory, community and voluntary sectors that are working with, or commissioning/funding services for people with dementia. Thank you to AGE UK and Mental Health Foundation who also contributed resources.

Differentiating dementia, delirium and depression

Nursing Times Learning has produced a new learning unit to assist in the differential diagnosis between dementia, delirium and depression in older people. The aim is to offer training / continuing professional development which helps ensure patients receive the most appropriate and effective care.

Alzheimer’s and Dementia Resources for Professionals
National Institutes on Aging

The National Institute on Aging has created a new online portal offering free clinical practice tools, training materials, and other resources for health professionals working with residents with cognitive impairments.

Free eBooks from Canada-flat-icon has compiled two eBooks, Making Evidence Matter in Canadian Health Policy and Canadian Health Policy in the News: Why Evidence Matters for use in your classrooms, for promotion on your websites and other media, and for your reading pleasure. These books are free to download and available in multiple formats, including for Apple, Google (Android) and Kindle devices, as well as PDF for desktop computers.

Briefing Note: Knowledge Sharing and Public Policy series – A Representation of Influence Processes Canada-flat-icon
National Collaborating Centre for Healthy Public Policy

This briefing note provides an overview of the processes through which public health knowledge can influence public policy.

CFHI: Organizational Assessment Tool Canada-flat-icon

The tool is built around six levers that will guide your organization toward making the changes needed to become a high-performing healthcare organization. For each lever, the tool includes statements that help you assess where your organization or system currently performs. These levers were developed after an examination of the key attributes of three high-performing healthcare organizations — Southcentral Foundation in Alaska, Jönköping County Council in Sweden, and Intermountain Healthcare in Utah (read the full paper) and a review of Canadian literature on healthcare transformation. Through assessment, this tool will help your organization or system:
-Identify improvement expertise, assets and strengths;
-Build improvement capacity, and;
-Take the next steps for healthcare improvement.

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