Translating Evidence-Based Falls Prevention into Clinical Practice in Nursing Facilities: Results and Lessons from a Quality Improvement Collaborative
Cathleen Colón-Emeric, MD, MHSc, Anna Schenck, PhD, Joel Gorospe, RN, MSN, Jill McArdle, RN, MSPH, Lee Dobson, MPA, Cindy DePorter, MSW, and Eleanor McConnell, RN, PhD, APRN, BC

OBJECTIVES: To describe the changes in process of care before and after an evidence-based fall reduction quality improvement collaborative in nursing facilities.

DESIGN: Natural experiment with nonparticipating facilities serving as controls.

SETTING: Community nursing homes.

PARTICIPANTS: Thirty-six participating and 353 nonparticipating nursing facilities in North Carolina.

INTERVENTION: Two in-person learning sessions, monthly teleconferences, and an e-mail discussion list over 9 months. The change package emphasized screening, labeling, and risk-factor reduction.

MEASUREMENTS: Compliance was measured using facility self-report and chart abstraction (n=832) before and after the intervention. Fall rates as measured using the Minimum Data Set (MDS) were compared with those of nonparticipating facilities as an exploratory outcome.

RESULTS: Self-reported compliance with screening, labeling, and risk-factor reduction approached 100%. Chart abstraction revealed only modest improvements in screening (51% to 68%, P<.05), risk-factor reduction (4% to 7%, P=.30), and medication assessment (2% to 6%, P=.34). There was a significant increase in vitamin D prescriptions (40% to 48%, P=.03) and decrease in sedative-hypnotics (19% to 12%, P=.04) but no change in benzodiazepine, neuroleptic, or calcium use. No significant changes in proportions of fallers or fall rates were observed according to chart abstraction (28.6% to 37.5%, P=.17), MDS (18.2% to 15.4%, P=.56), or self-report (6.1–5.6 falls/1,000 bed days, P=.31).

CONCLUSON: Multiple-risk-factor reduction tasks are infrequently implemented, whereas screening tasks appear more easily modifiable in a real-world setting. Substantial differences between self-reported practice and medical record documentation require that additional data sources be used to assess the change-in-care processes resulting from quality improvement programs. Interventions to improve interdisciplinary collaboration need to be developed. J Am Geriatr Soc 2006;54(9):1414-1418.


Satisfaction with End-of-Life Care for Nursing Home Residents with Advanced Dementia
Sharon E. Engel, Dan K. Kiely, MPH, MA, and Susan L. Mitchell, MD, MPH

OBJECTIVES: To identify factors associated with satisfaction with care for healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia.

DESIGN: Cross-sectional study.

SETTING: Thirteen NHs in Boston.

PARTICIPANTS: One hundred forty-eight NH residents aged 65 and older with advanced dementia and their formally designated HCPs.

MEASUREMENTS: The dependent variable was HCPs' score on the Satisfaction With Care at the End of Life in Dementia (SWC-EOLD) scale (range 10–40; higher scores indicate greater satisfaction). Resident characteristics analyzed as independent variables were demographic information, functional and cognitive status, comfort, tube feeding, and advance care planning. HCP characteristics were demographic information, health status, mood, advance care planning, and communication. Multivariate stepwise linear regression was used to identify factors independently associated with higher SWC-EOLD score.

RESULTS: The mean ages±standard deviation of the 148 residents and HCPs were 85.0±8.1 and 59.1±11.7, respectively. The mean SWC-EOLD score was 31.0±4.2. After multivariate adjustment, variables independently associated with greater satisfaction were more than 15 minutes discussing advance directives with a care provider at the time of NH admission (parameter estimate=2.39, 95% confidence interval (CI)=1.16–3.61, P<.001), greater resident comfort (parameter estimate=0.10, 95% CI=0.02–0.17, P=.01), care in a specialized dementia unit (parameter estimate=1.48, 95% CI=0.25–2.71, P=.02), and no feeding tube (parameter estimate=2.87, 95% CI=0.46–5.25, P=.02).

CONCLUSION: Better communication, greater resident comfort, no tube feeding, and care in a specialized dementia unit are modifiable factors that may improve satisfaction with care in advanced dementia. J Am Geriatr Soc 2006;54(10):1567-1572.


Reducing Suicidal Ideation in Depressed Older Primary Care Patients
Jürgen Unützer, MD, MPH, Lingqi Tang, PhD, Sabine Oishi, MSPH, Wayne Katon, MD, John W. Williams, Jr., MD, MHS, Enid Hunkeler, MA, Hugh Hendrie, MD, Elizabeth H.B. Lin, MD, MPH, Stuart Levine, MD, MHA, Lydia Grypma, MD, David C. Steffens, MD, MHSc, Julie Fields, BA, and Christopher Langston, PhD; for the IMPACT Investigators

OBJECTIVES: To determine the effect of a primary care–based collaborative care program for depression on suicidal ideation in older adults.

DESIGN: Randomized, controlled trial.

SETTING: Eighteen diverse primary care clinics.

PARTICIPANTS: One thousand eight hundred one adults aged 60 and older with major depression or dysthymia.

INTERVENTION: Participants randomized to collaborative care had access to a depression care manager who supported antidepressant medication management prescribed by their primary care physician and offered a course of Problem Solving Treatment in Primary Care for 12 months. Participants in the control arm received care as usual.

MEASUREMENTS: Participants had independent assessments of depression and suicidal ideation at baseline and 3, 6, 12, 18, and 24 months. Depression was assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (SCID). Suicidal ideation was determined using the SCID and the Hopkins Symptoms Checklist.

RESULTS: At baseline, 139 (15.3%) intervention subjects and 119 (13.3%) controls reported thoughts of suicide. Intervention subjects had significantly lower rates of suicidal ideation than controls at 6 months (7.5% vs 12.1%) and 12 months (9.8% vs 15.5%) and even after intervention resources were no longer available at 18 months (8.0% vs 13.3%) and 24 months (10.1% vs 13.9%). There were no completed suicides in either group. Information on suicide attempts or hospitalization for suicidal ideation was not available.

CONCLUSION: Primary care–based collaborative care programs for depression represent one strategy to reduce suicidal ideation and potentially the risk of suicide in older primary care patients. J Am Geriatr Soc 2006;54(10):1550-1556.


A Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing Home–Acquired Pneumonia in a State Veterans Home
Evelyn Hutt, MD, J. Mark Ruscin, PharmD, Kitty Corbett, PhD, MPH, Tiffany A. Radcliff, PhD, Andrew M. Kramer, MD, Elizabeth M. Williams, RN, Debra Liebrecht, RN, William Klenke, RN, Sheryl Hartmann, BA

OBJECTIVES: To assess the feasibility of a multifaceted strategy to translate evidence-based guidelines for treating nursing home–acquired pneumonia (NHAP) into practice using a small intervention trial.

DESIGN: Pre-posttest with untreated control group.

SETTING: Two Colorado State Veterans Homes (SVHs) during two influenza seasons.

PARTICIPANTS: Eighty-six residents with two or more signs of lower respiratory tract infection.

INTERVENTION: Multifaceted, including a formative phase to modify the intervention, institutional-level change emphasizing immunization, and availability of appropriate antibiotics; interactive educational sessions for nurses; and academic detailing.

MEASUREMENTS: Subjects' SVH medical records were reviewed for guideline compliance retrospectively for the influenza season before the intervention and prospectively during the intervention. Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test.

RESULTS: At the intervention facility, compliance with five of the guidelines improved: influenza vaccination, timely physician response to illness onset, x-ray for patients not being hospitalized, use of appropriate antibiotics, and timely antibiotic initiation for unstable patients. Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year.

CONCLUSION: Multifaceted, evidence-based, NHAP guideline implementation improved care processes in a SVH. Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents. J Am Geriatr Soc 2006;54(11):1694-1700.


Can Hip Protector Use Cost-Effectively Prevent Fractures in Community-Dwelling Geriatric Populations?
Lisa A. Honkanen, MD, MA, Alvin I. Mushlin, MD, ScM, Mark Lachs, MD, MPH, and Bruce R. Schackman, PhD

OBJECTIVES: To estimate the cost-effectiveness from a societal perspective of a hip protector (HP) program over the remaining lifetime of individuals initially living at home.

DESIGN: A state-transition Markov model considering outcomes of HP use in cohorts stratified by age, sex, and functional and residential status. Costs, transition probabilities, HP adherence, and efficacy were derived from published sources.

SETTING: Community and nursing homes in the United States.

PARTICIPANTS: Hypothetical cohort of individuals aged 65 and older without a hip fracture and initially living at home.

INTERVENTION: HP program.

MEASUREMENTS: Fractures, life years, and dollars saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER).
RESULTS: HP use prevented fractures and increased life expectancy in all cohorts. HP use saved costs and improved QALYs in women initiating HP use at age 80 and in men at age 85. In women initiating HP use at age 75, the HP ICER was $19,000/QALY. In men initiating HP use at age 80, HP use saved costs but slightly decreased QALYs. In younger cohorts, HP use was neither cost saving nor QALY improving. In sensitivity analyses, if there was no QALY loss from wearing a HP, the ICER was less than $50,000/QALY for all age and sex cohorts. If HP cost was reduced 50%, HP use was cost saving for women initiating HP use at age 75. In probabilistic sensitivity analyses, the HP ICER was less than $50,000/QALY in 68% of simulations for women initiating HP use at age 75 and 61% of simulations for men initiating at age 85.

CONCLUSION: HP use saved costs and QALYs for older age cohorts of both sexes. Additional research on the quality-of-life effects and obstacles to wearing HP is warranted. J Am Geriatr Soc 2006;54(11):1658-1665.


BRIEF METHODOLOGICAL REPORTS
Sensitivity and Specificity of the Mini-Mental State Examination for Identifying Dementia in the Oldest-Old: The 90+ Study
Kristin Kahle-Wrobleski, PhD, Maria M. Corrada, ScD, Bixia Li, MS, and Claudia H. Kawas, MD

OBJECTIVES: To evaluate the sensitivity and specificity of the Mini-Mental State Examination (MMSE) in identifying dementia in the oldest-old when stratified by age and education.

DESIGN: Cross-sectional.

SETTING: Research clinic and in-home visits.

PARTICIPANTS: Population-based sample of adults aged 90 and older (n=435) who are enrolled in the 90+ Study, a longitudinal, population-based study.

MEASUREMENTS: Neurological examination to determine dementia diagnosis, MMSE, and demographic data.

RESULTS: Receiver operating characteristic (ROC) analyses indicated that the MMSE had high diagnostic accuracy for identifying dementia in subjects aged 90 and older across different age and education groups (area under the ROC curve values ranged from 0.82 to 0.98). A range of possible cutoff values and corresponding sensitivity and specificity are provided for the following age groups: 90–93, 94–96, and ≥97. Age groups were subdivided by educational attainment (≤high school, vocational school or some college, college degree or higher). In subjects aged 90 to 93 with a college degree or higher, the suggested MMSE cutoff score is ≤25 (sensitivity=0.82, specificity=0.80). In those aged 94 to 96 with a college degree or higher, the suggested cutoff is ≤24 (sensitivity=0.85, specificity=0.80). Those aged 97 and older with an education of high school or less had the lowest suggested cutoff ≤22 (sensitivity=0.80, specificity=0.76).

CONCLUSION: Overall, the MMSE had good sensitivity and specificity across all age and educational groups. Optimal cutoff points were lower in the older age groups and those with less education, primarily to preserve specificity. This screening instrument is appropriate for use with the oldest-old. J Am Geriatr Soc 2007;55(2):284-289.