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AIMS: To identify clusters of risk factors in home health care and determine if the clusters are associated with hospitalizations or emergency department visits. DESIGN: A retrospective cohort study. METHODS: This study included 61,454 patients pertaining to 79,079 episodes receiving home health care between 2015 and 2017 from one of the largest home health care organizations in the United States. Potential risk factors were extracted from structured data and unstructured clinical notes analysed by natural language processing. A K-means cluster analysis was conducted. Kaplan–Meier analysis was conducted to identify the association between clusters and hospitalizations or emergency department visits during home health care. RESULTS: A total of 11.6% of home health episodes resulted in hospitalizations or emergency department visits. Risk factors formed three clusters. Cluster 1 is characterized by a combination of risk factors related to “impaired physical comfort with pain,” defined as situations where patients may experience increased pain. Cluster 2 is characterized by “high comorbidity burden” defined as multiple comorbidities or other risks for hospitalization (e.g., prior falls). Cluster 3 is characterized by “impaired cognitive/psychological and skin integrity” including dementia or skin ulcer. Compared to Cluster 1, the risk of hospitalizations or emergency department visits increased by 1.95 times for Cluster 2 and by 2.12 times for Cluster 3 (all p < .001). CONCLUSION: Risk factors were clustered into three types describing distinct characteristics for hospitalizations or emergency department visits. Different combinations of risk factors affected the likelihood of these negative outcomes. IMPACT: Cluster-based risk prediction models could be integrated into early warning systems to identify patients at risk for hospitalizations or emergency department visits leading to more timely, patient-centred care, ultimately preventing these events. PATIENT OR PUBLIC CONTRIBUTION: There was no involvement of patients in developing the research question, determining the outcome measures, or implementing the study.

BACKGROUND: About one in five patients receiving home health care (HHC) services are hospitalized or visit an emergency department (ED) during a home care episode. Early identification of patients at risk can prevent these negative outcomes. However, risk indicators, including language in clinical notes that indicate a concern about a patient, are often hidden in narrative documentation throughout their HHC episode. OBJECTIVE: To develop an automated natural language processing (NLP) algorithm to identify concerning language indicative of HHC patient risk of hospitalizations or ED visits. METHODS: This study used the Omaha System—a standardized nursing terminology that describes problems/signs/symptoms that can occur in the community setting. First, five HHC experts iteratively reviewed the Omaha System and identified concerning concepts indicative of HHC patient risk of hospitalizations or ED visits. Next, we developed and tested an NLP algorithm to identify these concerning concepts in HHC clinical notes automatically. The resulting NLP algorithm was applied on a large subset of narrative notes (2.3 million notes) documented for 66,317 unique patients (n = 87,966 HHC episodes) admitted to one large HHC agency in the Northeast United States between 2015 and 2017. RESULTS: A total of 160 Omaha System signs/symptoms were identified as concerning concepts for hospitalizations or ED visits in HHC. These signs/symptoms belong to 31 of the 42 available Omaha System problems. Overall, the NLP algorithm showed good performance in identifying concerning concepts in clinical notes. More than 18% of clinical notes were detected as having at least one concerning concept, and more than 90% of HHC episodes included at least one Omaha System problem. The most frequently documented concerning concepts were pain, followed by issues related to neuro-musculoskeletal function, circulation, mental health, and communicable/infectious conditions. CONCLUSION: Our findings suggest that concerning problems or symptoms that could increase the risk of hospitalization or ED visit were frequently documented in narrative clinical notes. NLP can automatically extract information from narrative clinical notes to improve our understanding of care needs in HHC. Next steps are to evaluate which concerning concepts identified in clinical notes predict hospitalization or ED visit.

Context To date, no studies have characterized the impacts of urinary incontinence (UI) at the end of life in the home hospice (HH) setting. UI is highly prevalent at the end of life and adversely affects quality of life. Objectives To characterize HH nurses’ perspectives on UI in HH patients. Methods We conducted a qualitative descriptive study of interviews between HH nurses and the study investigator. Thirty-two interviews with HH nurses were transcribed and analyzed. Nurses were mostly female, college-educated, and had several years of experience in HH nursing. Results We identified findings in four major themes: 1) HH nurses' definition and identification of UI, 2) the absence of formal guidelines for diagnosing UI in HH patients, 3) UI's adverse effect on HH patients and their families, and 4) the lack of standardized guidelines for the management of UI in the HH setting. We found that there was a general lack of clarity on the subtypes of UI and no standardized guidelines for management of UI in the HH setting. Nurses reported that UI was bothersome to HH patients and their caregivers, citing patient discomfort, loss of dignity, and additional labor burden as reasons for this. Management strategies for UI lacked standardization. Conclusion UI is a prevalent and debilitating condition in HH patients. There is a need for studies to further characterize the impacts of UI on HH patients and their caregivers. Formal training on UI subtypes and management is needed to facilitate proper documentation, research, and improve patient outcomes.

Background Infection Prevention and Control (IPC) practices have been established in home health care. Adherence to IPC practices has been suboptimal with limited available evidence. The study aim was to examine the impact of individual, home environment, and organizational factors on IPC practices using human factors model. Methods Three hundred and fifty-three nurses were surveyed across two large home care agencies to examine the relationship between IPC adherence and individual, home environment, and organizational factors. Results Nurses reported multiple barriers to IPC practices in patients’ homes (mean = 4.34, standard deviation = 2.53). Frequent barriers included clutter (reported by 74.5% of nurses) and a dirty environment (70.3%). Nurses also reported limited availability of some IPC supplies (mean = 7.76, standard deviation = 2.44), including personal protective equipment. Home environment factors were significant barriers, and availability of IPC supplies were significant enablers of IPC adherence. Agency-provided training and decision-making resources were not significant factors for IPC adherence in the presence of home environment barriers and IPC supplies. Conclusions This study findings suggest that IPC adherence strategies point to addressing barriers in the home environment and increasing availability of IPC supplies. The relationship between the patient's home environment, organizational factors, and IPC practices among home health care nurses warrants further study.

Information does not yet exist on the characteristics and outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) who are discharged to the home setting. Using rich data from home health care (HHC), the authors describe characteristics of COVID-19 survivors upon admission to HHC, the home visits they received, and the extent of recovery among those discharged from HHC. They also profile the risk factors associated with rehospitalization and death., Background: Little is known about recovery from coronavirus disease 2019 (COVID-19) after hospital discharge. Objective: To describe the home health recovery of patients with COVID-19 and risk factors associated with rehospitalization or death. Design: Retrospective observational cohort. Setting: New York City. Participants: 1409 patients with COVID-19 admitted to home health care (HHC) between 1 April and 15 June 2020 after hospitalization. Measurements: Covariates and outcomes were obtained from the mandated OASIS (Outcome and Assessment Information Set). Cox proportional hazard models were used to estimate the hazard ratio (HR) of risk factors associated with rehospitalization or death. Results: After an average of 32 days in HHC, 94% of patients were discharged and most achieved statistically significant improvements in symptoms and function. Activity-of-daily-living dependencies decreased from an average of 6 (95% CI, 5.9 to 6.1) to 1.2 (CI, 1.1 to 1.3). Risk for rehospitalization or death was higher for male patients (HR, 1.45 [CI, 1.04 to 2.03]); White patients (HR, 1.74 [CI, 1.22 to 2.47]); and patients with heart failure (HR, 2.12 [CI, 1.41 to 3.19]), diabetes with complications (HR, 1.71 [CI, 1.17 to 2.52]), 2 or more emergency department visits in the past 6 months (HR, 1.78 [CI, 1.21 to 2.62]), pain daily or all the time (HR, 1.46 [CI, 1.05 to 2.05]), cognitive impairment (HR, 1.49 [CI, 1.04 to 2.13]), or functional dependencies (HR, 1.09 [CI, 1.00 to 1.20]). Eleven patients (1%) died, 137 (10%) were rehospitalized, and 23 (2%) remain on service. Limitations: Care was provided by 1 home health agency. Information on rehospitalization and death after HHC discharge is not available. Conclusion: Symptom burden and functional dependence were common at the time of HHC admission but improved for most patients. Comorbid conditions of heart failure and diabetes, as well as characteristics present at admission, identified patients at greatest risk for an adverse event. Primary Funding Source: No direct funding.

There has been limited research into the individual, social, and environmental factors for infection risk among patients in the home healthcare (HHC) setting, where the infection is a leading cause of hospitalisation. The aims of this study were to (1) explore nurse perceptions of individual, social, and environmental factors for infection risk among HHC patients; and (2) identify the frequency of environmental barriers to infection prevention and control in HHC. Data were collected in 2017-2018 and included qualitative interviews with HHC nurses (n = 50) and structured observations of nurse visits to patients' homes (n = 400). Thematic analyses of interviews with nurses suggested they perceived infection risk among patients as being influenced by knowledge of and attitudes towards infection prevention and engagement in hygiene practices, receipt of support from informal caregivers and nurse interventions aimed at cultivating infection control knowledge and practices, and the home environment. Statistical analyses of observation checklists revealed nurses encountered an average of 1.7 environmental barriers upon each home visit. Frequent environmental barriers observed during visits to HHC patients included clutter (39.5%), poor lighting (38.8%), dirtiness (28.5%), and pets (17.2%). Additional research is needed to clarify inter-relationships among these factors and identify strategies for addressing each as part of a comprehensive infection control program in HHC.

Objective The study sought to outline how a clinical risk prediction model for identifying patients at risk of infection is perceived by home care nurses, and to inform how the output of the model could be integrated into a clinical workflow. Materials and Methods This was a qualitative study using semi-structured interviews with 50 home care nurses. Interviews explored nurses’ perceptions of clinical risk prediction models, their experiences using them in practice, and what elements are important for the implementation of a clinical risk prediction model focusing on infection. Interviews were audio-taped and transcribed, with data evaluated using thematic analysis. Results Two themes were derived from the data: (1) informing nursing practice, which outlined how a clinical risk prediction model could inform nurse clinical judgment and be used to modify their care plan interventions, and (2) operationalizing the score, which summarized how the clinical risk prediction model could be incorporated in home care settings. Discussion The findings indicate that home care nurses would find a clinical risk prediction model for infection useful, as long as it provided both context around the reasons why a patient was deemed to be at high risk and provided some guidance for action. Conclusions It is important to evaluate the potential feasibility and acceptability of a clinical risk prediction model, to inform the intervention design and implementation strategy. The results of this study can provide guidance for the development of the clinical risk prediction tool as an intervention for integration in home care settings.

Objective To assess the overlap of information between electronic health record (EHR) and patient–nurse verbal communication in home healthcare (HHC). Methods Patient–nurse verbal communications during home visits were recorded between February 16, 2021 and September 2, 2021 with patients being served in an organization located in the Northeast United States. Twenty-two audio recordings for 15 patients were transcribed. To compare overlap of information, manual annotations of problems and interventions were made on transcriptions as well as information from EHR including structured data and clinical notes corresponding to HHC visits. Results About 30% (1534/5118) of utterances (ie, spoken language preceding/following silence or a change of speaker) were identified as including problems or interventions. A total of 216 problems and 492 interventions were identified through verbal communication among all the patients in the study. Approximately 50.5% of the problems and 20.8% of the interventions discussed during the verbal communication were not documented in the EHR. Preliminary results showed that statistical differences between racial groups were observed in a comparison of problems and interventions. Discussion This study was the first to investigate the extent that problems and interventions were mentioned in patient–nurse verbal communication during HHC visits and whether this information was documented in EHR. Our analysis identified gaps in information overlap and possible racial disparities. Conclusion Our results highlight the value of analyzing communications between HHC patients and nurses. Future studies should explore ways to capture information in verbal communication using automated speech recognition.

Infection prevention is a high priority for home healthcare (HHC) but tools are lacking to identify patients at highest risk for developing infections. The purpose of this study was to develop and test a predictive risk model to identify HHC patients at risk of an infection-related hospitalization or emergency department visit. A non-experimental study using secondary data was conducted. The Outcome and Assessment Information Set linked with relevant clinical data from 112,788 HHC admissions in 2014 were used for model development (70% of data) and testing (30%). A total of 1,908 patients (1.69%) were hospitalized or received emergency care associated with infection. Stepwise logistic regression models discriminated between individuals with and without infections. Our final model, when classified by highest risk of infection, identified a high portion of those who were hospitalized or received emergent care for an infection while also correctly categorizing 90.5% of patients without infection. The risk model can be used by clinicians to inform care planning. This is the first study to develop a tool for predicting infection risk that can be used to inform how to direct additional infection control intervention resources on high-risk patients, potentially reducing infection related hospitalizations, emergency department visits, and costs.

BACKGROUND/OBJECTIVE: Between 10 and 25% patients are hospitalized or visit emergency department (ED) during home healthcare (HHC). Given that up to 40% of these negative clinical outcomes are preventable, early and accurate prediction of hospitalization risk can be one strategy to prevent them. In recent years, machine learning-based predictive modeling has become widely used for building risk models. This study aimed to compare the predictive performance of four risk models built with various data sources for hospitalization and ED visits in HHC. METHODS: Four risk models were built using different variables from two data sources: structured data (i.e., Outcome and Assessment Information Set (OASIS) and other assessment items from the electronic health record (EHR)) and unstructured narrative-free text clinical notes for patients who received HHC services from the largest non-profit HHC organization in New York between 2015 and 2017. Then, five machine learning algorithms (logistic regression, Random Forest, Bayesian network, support vector machine (SVM), and Naïve Bayes) were used on each risk model. Risk model performance was evaluated using the F-score and Precision-Recall Curve (PRC) area metrics. RESULTS: During the study period, 8373/86,823 (9.6%) HHC episodes resulted in hospitalization or ED visits. Among five machine learning algorithms on each model, the SVM showed the highest F-score (0.82), while the Random Forest showed the highest PRC area (0.864). Adding information extracted from clinical notes significantly improved the risk prediction ability by up to 16.6% in F-score and 17.8% in PRC. CONCLUSION: All models showed relatively good hospitalization or ED visit risk predictive performance in HHC. Information from clinical notes integrated with the structured data improved the ability to identify patients at risk for these emergent care events.

Background Home health care (HHC) is a leading form of home and community-based services for persons with dementia (PWD). Nurses are the primary providers of HHC; however, little is known of nursing care delivery and quality. Objective The objective of this study was to examine the association between continuity of nursing care in HHC and rehospitalization among PWD. Research design This is a retrospective cohort study using multiple years (2010-2015) of HHC assessment, administrative, and human resources data from a large urban not-for-profit home health agency. Subjects This study included 23,886 PWD receiving HHC following a hospitalization. Measures Continuity of nursing care was calculated using the Bice and Boxerman method, which considered the number of total visits, nurses, and visits from each nurse during an HHC episode. The outcome was all-cause rehospitalization during HHC. Risk-adjusted logistic regression was used for analysis. Results Approximately 24% of PWD were rehospitalized. The mean continuity of nursing care score was 0.56 (SD=0.33). Eight percent of PWD received each nursing visit from a different nurse (no continuity), and 26% received all visits from one nurse during an HHC episode (full continuity). Compared with those receiving high continuity of nursing care (third tertile), PWD receiving low (first tertile) or moderate (second tertile) continuity of nursing care had an adjusted odds ratio of 1.33 (95% confidence interval: 1.25-1.46) and 1.30 (95% confidence interval: 1.22-1.43), respectively, for being rehospitalized. Conclusions Wide variations exist in continuity of nursing care to PWD. Consistency in nurse staff when providing HHC visits to PWD is critical for preventing rehospitalizations.

Background Despite improvements in hypertension treatment in the United States, Black and Hispanic individuals experience poor blood pressure control and have worse hypertension-related outcomes compared to Whites. Objective The aim of the study was to determine the effect on hospitalization of supplementing usual home care (UHC) with two hypertension-focused transitional care interventions-one deploying nurse practitioners (NPs) and the other NPs plus health coaches. Methods We examined post hoc the effect of two hypertension-focused NP interventions on hospitalizations in the Community Transitions Intervention trial-a three-arm, randomized controlled trial comparing the effectiveness of (a) UHC with (b) UHC plus a 30-day NP transitional care intervention or (c) UHC plus NP plus 60-day health coach intervention. Results The study comprised 495 participants: mean age = 66 years; 57% female; 70% Black, non-Hispanic; 30% Hispanic. At the 3- and 12-month follow-up, all three groups showed a significant decrease in the average number of hospitalizations compared to baseline. The interventions were not significantly different from UHC. Conclusion The results of this post hoc analysis show that, during the study period, decreases in hospitalizations in the intervention groups were comparable to those in UHC, and deploying NPs provided no detectable value added. Future research should focus on testing ways to optimize UHC services.

BACKGROUND Delayed start-of-care nursing visits in home health care (HHC) can result in negative outcomes, such as hospitalization. No previous studies have investigated why start-of-care HHC nursing visits are delayed, in part because most reasons for delayed visits are documented in free-text HHC nursing notes. OBJECTIVE The aims of this study were to (1) develop and test a natural language processing (NLP) algorithm that automatically identifies reasons for delayed visits in HHC free-text clinical notes and (2) describe reasons for delayed visits in a large patient sample. METHODS This study was conducted at the Visiting Nurse Service of New York (VNSNY). We examined data available at the VNSNY on all new episodes of care started in 2019 (N=48,497). An NLP algorithm was developed and tested to automatically identify and classify reasons for delayed visits. RESULTS The performance of the NLP algorithm was 0.8, 0.75, and 0.77 for precision, recall, and F-score, respectively. A total of one-third of HHC episodes (n=16,244) had delayed start-of-care HHC nursing visits. The most prevalent identified category of reasons for delayed start-of-care nursing visits was no answer at the door or phone (3728/8051, 46.3%), followed by patient/family request to postpone or refuse some HHC services (n=2858, 35.5%), and administrative or scheduling issues (n=1465, 18.2%). In 40% (n=16,244) of HHC episodes, 2 or more reasons were documented. CONCLUSIONS To avoid critical delays in start-of-care nursing visits, HHC organizations might examine and improve ways to effectively address the reasons for delayed visits, using effective interventions, such as educating patients or caregivers on the importance of a timely nursing visit and improving patients’ intake procedures.

According to the U.S. census Bureau, close to 20% of the U.S. population speaks a language other than English at home. Home health care (HHC) patients who speak English less than very well or have limited English proficiency (LEP) are at an increased risk for medication mismanagement and serious health consequences. The purpose of this study was to examine if there were differences in medication management between English-speaking patients and patients with LEP receiving HHC services. Data for this cross-sectional observation study were collected from 2010 to 2014. Medication management was measured by two items in the Centers for Medicare and Medicaid Services–mandated Outcomes Assessment Information Set (OASIS). All patients in the database who were taking medications and had a valid admission and discharge assessment from HHC were included in the analysis. Inverse probability of treatment weighting (IPTW) with a marginal structural model was used to address potential imbalances in observed patient characteristics when estimating the effect of having LEP or being an English-speaking HHC patient on changes in medication management over the course of a HHC episode. Estimates from marginal structural model with inverse probability weighting indicate that being LEP was associated with less improvement in medication management and increased likelihood of getting worse over the course of a HHC episode. This study is one of the first to demonstrate that patients with LEP experience disparities in medication management when compared to English-speaking patients in HHC.

Objectives Home health care patients have critical needs requiring timely care following hospital discharge. Although Medicare requires timely start-of-care nursing visits, a significant portion of home health care patients wait longer than 2 days for the first visit. No previous studies investigated the pattern of start-of-care visits or factors associated with their timing. This study's purpose was to examine variation in timing of start-of-care visits and characterize patients with visits later than 2 days postdischarge. Design Retrospective cohort study. Setting/participants Patients admitted to a large, Northeastern US, urban home health care organization during 2019. The study included 48,497 home care episodes for 45,390 individual patients. Measurement We calculated time to start of care from hospital discharge for 2 patient groups: those seen within 2 days vs those seen >2 days postdischarge. We examined patient factors, hospital discharge factors, and timing of start of care using multivariate logistic regression. Results Of 48,497 episodes, 16,251 (33.5%) had a start-of-care nursing visit >2 days after discharge. Increased odds of this time frame were associated with being black or Hispanic and having solely Medicaid insurance. Odds were highest for patients discharged on Fridays, Saturdays, and Mondays. Factors associated with visits within 2 days included surgical wound presence, urinary catheter, pain, 5 or more medications, and intravenous or infusion therapies at home. Conclusions and Implications Findings provide the first publication of clinical and demographic characteristics associated with home health care start-of-care timing and its variation. Further examination is needed, and adjustments to staff scheduling and improved information transfer are 2 suggested interventions to decrease variation.

Healthcare-associated infections are a significant reason for readmission to hospital post-discharge to the community. In this paper, the authors describe some of the key findings from a programme of work conducted in a home care agency (community care organisation) in the US. A survey was conducted to explore home care nurses' knowledge, attitudes and beliefs around infection control (n=415); 400 nurse-patient visits were observed, and 50 nurses were interviewed about their infection control practices. Nurses reported high compliance with infection control practices. However, the overall average adherence rate to observed hand hygiene practices was 45.6%. Interview data provided valuable insights into specific challenges faced by nurses in a home care setting. This study provides insights that can be used to enhance infection control practice in community care in the UK.

Introduction: Mental health issues are on an exponential rise in Kashmir due to varied reasons including political instability, eco fragility, the growing lag in the provision of education and employment, and several other reasons. Impediments such as the overwhelming stigma and the cultural sensitivity associated with mental health issues both sustain and perpetuate mental ill health and also prevent any treatment and rehabilitation. This article describes the protocol of a research project, funded by the Indian Council of Medical Research, which aims to address this issue. Aim: To screen the population for mental health issues and to provide community-based intervention for the identified cases also to train community health workers for sustainable mental health support. Methods: We will conduct a household survey using the Hopkins Symptom Checklist (HSCL-25) for the identification of the clients. A multi-stage random sampling shall be used to select the villages and the households from the marginalized communities. A sample of 500 respondents shall be screened using HSCL-25. Those who screen positive for mental health issues will be offered cognitive behavioral therapy (CBT) by a qualified clinical psychologist. The research will be able to address the diagnosis of depression and anxiety-related cases and the subsequent intervention. Additionally, we will utilize the facilitator’s manual for Mental Health Training Program for Community Health Workers to build sustainable mental health services in community settings. Discussion: The study shall present a roadmap focusing on the indispensability of a comprehensive community-based intervention on mental health utilizing a non-pharmacological method. Assessing and analyzing the dynamics of mental health illness first hand, the study shall move ahead to offer a culturally tailored counseling program at the community level. The study also aims to highlight the role of the indigenous human resource (community health workers) and how its participation leads to a more scientific and sustainable intervention for more effective results, with an increased level of awareness and sensitization in a conventional society like Kashmir.

Background: Bridging the alarming treatment gap for mental disorders in India requires a monumental effort from all stakeholders. Harnessing digital technology is one of the potential ways to leapfrog many known barriers for capacity building. Aim and Context: The ongoing Virtual Knowledge Network (VKN)–National Institute of Mental Health and Neurosciences (NIMHANS)–Extension of Community Health Outcomes (ECHO) (VKN–NIMHANS–ECHO: hub and spokes model) model for skilled capacity building is a collaborative effort between NIMHANS and the University of New Mexico Health Sciences Centre, USA. This article aims to summarize the methodology of two randomized controlled trials funded by the Indian Council of Medical Research (ICMR) designed to evaluate the effectiveness of the VKN–NIMHANS–ECHO model of training as compared to training as usual (TAU). Methods: Both RCTs were conducted in Karnataka, a southern Indian state in which the DMHP operates in all districts. We compared the impact of the following two models of capacity building for the DMHP workforce (a) the VKN–NIMHANS–ECHO model and (b) the traditional method. We use the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement to describe the methods of these two trials. Trial 1 is to evaluate the “Effectiveness of addition of Virtual-NIMHANS–ECHO tele-mentoring model for skilled capacity building in providing quality care in alcohol use disorders by the existing staff of DMHP districts of Karnataka.” Hub for trial 1 was set up at NIMHANS and the spokes were psychiatrists and other mental health professionals headquartered in the district level office. Trial 2 assesses the implementation and evaluation of the NIMHANS–ECHO blended training program for the DMHP workforce in a rural south-Indian district of Karnataka state. The hub for trial 2 was set up in the district headquarter of Ramanagaram. Hub specialists are DMHP psychiatrists, whereas spokes are the non-doctor workforce (including auxiliary nurse midwives [ANMs] and accredited social health activists [ASHA] workers) medical officers of primary health centers. The location of the HubHub differs in these two studies. Both trials are funded by the ICMR, Government of India Discussion: Both these trials, though conceptually similar, have some operational differences which have been highlighted. If demonstrated to be effective, this model of telementoring can be generalized and widely merged into the Indian health care system, thus aiding in reducing the treatment gap for patients unable to access care.

Objective To describe nurse hand hygiene practices in the home health care (HHC) setting, nurse adherence to hand hygiene guidelines, and factors associated with hand hygiene opportunities during home care visits. Design Observational study of nurse hand hygiene practices. Setting and Participants: Licensed practical/vocational and registered nurses were observed in the homes of patients being served by a large nonprofit HHC agency. Methods Two researchers observed 400 home care visits conducted by 50 nurses. The World Health Organization's “5 Moments for Hand Hygiene” validated observation tool was used to record opportunities and actual practices of hand hygiene, with 3 additional opportunities specific to the HHC setting. Patient assessment data available in the agency electronic health record and a nurse demographic questionnaire were also collected to describe patients and nurse participants. Results A total of 2014 opportunities were observed. On arrival in the home was the most frequent opportunity (n = 384), the least frequent was after touching a patient's surroundings (n = 43). The average hand hygiene adherence rate was 45.6% after adjusting for clustering at the nurse level. Adherence was highest after contact with body fluid (65.1%) and lowest after touching a patient (29.5%). The number of hand hygiene opportunities was higher when patients being served were at increased risk of an infection-related emergency department visit or hospitalization and when the home environment was observed to be “dirty.” No nurse or patient demographic characteristics were associated with the rate of nurse hand hygiene adherence. Conclusions and Implications Hand hygiene adherence in HHC is suboptimal, with rates mirroring those reported in hospital and outpatient settings. The connection between poor hand hygiene and infection transmission has been well studied, and it has received widespread attention with the outbreak of SARS-CoV-2. Agencies can use results found in this study to better inform quality improvement initiatives.

Background: Urinary tract infection (UTI) is a complication often experienced during a home health care (HHC) episode, yet related hospitalization risk factors are unclear. Objectives: This study use multiple data sources to identify risk factors for UTI related hospitalization or emergency department (ED) visits among HHC patients.Method: We performed a multivariable logistic regression to identify risk factors for UTI-related hospitalization or ED visits using merged data from the Outcome and Assessment Information Set, electronic health record from a large HHC agency, and Center for Medicare and Medicaid claims. Results: Of 48,336 cases, 1,689 patients (3.5%) had a UTI-related hospitalization/ED visits. Being a female (OR = 1.31; 95% CI: 1.16–1.46), the presence of a urinary catheter (OR = 5.7; 95% CI: 4.54–7.14), treatment with general antibacterial and antiseptics (OR = 2.75; 95% CI: 1.02–7.38), dependency in instrumental activities of daily living (e.g., meal preparation [OR=1.72; 95% CI: 1.25-2.37]), and no available caregivers (OR = 1.79; 95% CI: 1.2–2.68) increased the odds of a UTI related event among HHC patients. Discussion/conclusion: We identified notable risk factors for UTI related hospitalization/ER visit, filling a knowledge gap on the currently understudied HHC population. Risk factors identified in this study can be used to proactively identify HHC patients at risk for UTI related hospitalization and target them for preventive interventions. Further research is needed in HHC to develop tailored interventions for at-risk patients.

BACKGROUND Homecare settings across the United States provide care to more than 5 million patients every year. About one in five homecare patients are rehospitalized during the homecare episode, with up to two-thirds of these rehospitalizations occurring within the first 2 weeks of services. Timely allocation of homecare services might prevent a significant portion of these rehospitalizations. The first homecare nursing visit is one of the most critical steps of the homecare episode. This visit includes an assessment of the patient’s capacity for self-care, medication reconciliation, an examination of the home environment, and a discussion regarding whether a caregiver is present. Hence, appropriate timing of the first visit is crucial, especially for patients with urgent health care needs. However, nurses often have limited and inaccurate information about incoming patients, and patient priority decisions vary significantly between nurses. We developed an innovative decision support tool called Priority for the First Nursing Visit Tool (PREVENT) to assist nurses in prioritizing patients in need of immediate first homecare nursing visits. OBJECTIVE This study aims to evaluate the effectiveness of the PREVENT tool on process and patient outcomes and to examine the reach, adoption, and implementation of PREVENT. METHODS Employing a pre-post design, survival analysis, and logistic regression with propensity score matching analysis, we will test the following hypotheses: compared with not using the tool in the preintervention phase, when homecare clinicians use the PREVENT tool, high-risk patients in the intervention phase will (1) receive more timely first homecare visits and (2) have decreased incidence of rehospitalization and have decreased emergency department use within 60 days. Reach, adoption, and implementation will be assessed using mixed methods including homecare admission staff interviews, think-aloud observations, and analysis of staffing and other relevant data. RESULTS The study research protocol was approved by the institutional review board in October 2019. PREVENT is currently being integrated into the electronic health records at the participating study sites. Data collection is planned to start in early 2021. CONCLUSIONS Mixed methods will enable us to gain an in-depth understanding of the complex socio-technological aspects of the hospital to homecare transition. The results have the potential to (1) influence the standardization and individualization of nurse decision making through the use of cutting-edge technology and (2) improve patient outcomes in the understudied homecare setting. CLINICALTRIAL ClinicalTrials.gov NCT04136951; https://clinicaltrials.gov/ct2/show/NCT04136951 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/20184

BackgroundThere is an increase in the number of individuals who receive care at home. A significant proportion of these patients acquire infections during their care episode. Whilst there has been significant focus on strategies for infection prevention and control in acute care environments, there is a lack of research into infection prevention in a home care setting.ObjectivesTo understand 1) if and how home care nurses identify patients at high risk of infection and 2) the strategies they use to mitigate that risk.DesignA qualitative descriptive study, using semi-structured interviews.SettingA large not for profit home care agency located in the New York region of the United States.ParticipantsFifty nurses with a range of experience in home care nursing.MethodsPurposive and snowball sampling was used to recruit nurses from across the home care agency with varied years of work experience. Interviews were audio recorded andtranscribed. The interviews explored how home care nurses evaluate their patients’ risk of developing an infection and if/how they modify the plan of care based on that risk. Data were analysed using thematic analysis.ResultsThree themes were derived from the data; assessing a patient’s risk of infection, the risk assessment process, and strategies for mitigating infection risk. Factors identified by nurses as putting a patient at higher risk of infection included being older, having diabetes, inadequate nutrition; along with inadequate clinical information available at start of care. The patient’s knowledge and understanding of infection prevention, and the availability and knowledge of caregivers were also important, as was the cleanliness of the home environment. Given the context of home care, where nurses have little control over the environment and care processes in-between visits, the main strategy for infection prevention was patient and caregiver education. Nurses also discussed the importance of their own infection prevention behaviours, and the ability to adjust a patient’s plan of care according to their infection risk.ConclusionsThe study highlights the complexity of the risk assessment process in relation to infection. Existing guidelines for infection prevention and control do not adequately cover the home care environment and more research needs to determine which interventions (such as patient/caregiver education) would be most effective to prevent infections in the home care setting.

Hemophilia B requires replacement therapy with factor IX (FIX) coagulation products to treat and prevent bleeding episodes. A recently introduced extended half-life (EHL) recombinant FIX replacement product provided the opportunity to compare the amount of dispensed factor and expenditures for EHL treatment compared with a standard half-life (SHL) product.To determine factor international units (IUs) dispensed and expenditures associated with switching from nonacog alfa, the most commonly used SHL replacement product, to eftrenonacog alfa, an EHL FIX replacement product.Two U.S. claims databases were analyzed. A large national specialty pharmacy dispensation claims database was used to identify the number of IUs dispensed and monthly charges for all patients with hemophilia B from April 2015 to June 2016. Truven Health MarketScan Research Databases (January 2010-July 2016) were used to identify IUs and expenditures for patients with claims data for at least 3 months before and after switching from the SHL to the EHL product. Medians for IUs and expenditures are presented to accommodate for skewness of data distribution.The national specialty pharmacy database analysis included 296 patients with moderate or severe hemophilia B (233 on SHL; 94 on EHL). Median monthly factor dispensed was 11% lower (2,142 IU) in the EHL versus SHL cohort over the study period, while individual monthly reductions ranged from 32% to 47% (9,838 IU to 16,514 IU). Using the wholesale acquisition cost, the median per-patient monthly factor expenditures over the 15-month study period were 94% higher ($23,005) for the EHL than for the SHL product. Individual median monthly expenditure differences ranged from 15% ($6,562) to 49% ($19,624). In the Truven database, 14 patients switched from the SHL to the EHL product. The amount of factor dispensed was variable; in the 1-year period before and after the switch from the SHL to the EHL product, mean IUs dispensed decreased by 3,005 IU, while median IUs dispensed increased by 4,775 IU. Factor replacement expenditures were higher after switching from the SHL to the EHL product in each of the 3-month periods examined before versus after the switch.This analysis of real-world data showed that switching from the SHL to the EHL product was associated with higher expenditures. Increased expenditures noted in the first 3 months after switching may be related to initial stocking up of the EHL product, but expenditures were sustained throughout the 1-year period of data analysis. Further analysis of these findings with larger numbers of patients should be explored.This study was sponsored by Pfizer. Pfizer employees were involved in the study design; the collection, analysis, and interpretation of data; the review of the manuscript; and the decision to submit for publication. All authors are employees of Pfizer. No author received an honorarium or other form of payment related to the development of this manuscript. All authors participated in the study design, data interpretation, and manuscript review and revisions and granted approval for the submission of the manuscript. Alvir, McDonald, and Tortella also participated in data analysis. Data from this paper were presented in part at the European Association for Haemophilia and Allied Disorders Annual Meeting, February 1-3, 2017, Paris, France; at the International Society for Pharmacoeconomics and Outcomes Research Annual Meeting, May 20-24, 2017, Boston, MA; and at the International Society on Thrombosis and Haemostasis Congress, July 8-13, 2017, Berlin, Germany.

Markay Hopps,Laura Iadeluca,Margaret McDonald,Geoffrey T MakinsonPfizer Inc., New York, NY, USA Background: Family caregiving is an increasingly important component of care for patients and the elderly. Objective: The aim of this study is to characterize the burden of family caregiving among employed adults. Methods: Employed adults (≥18years) from the 2013 US National Health and Wellness Survey (NHWS) were classified as family caregivers if they reported currently caring for at least one adult relative. Chi-square tests and one-way analyses of variance assessed whether employed caregivers, weighted to the US population, differed from employed non-caregivers on behavioral characteristics, workplace productivity, and health care resource utilization. Results: Eight million workers were family caregivers in the United States, more often female than male (51% vs. 49%, P < 0.05), and 53% were between 40 and 64years of age. Eighteen percent of caregivers were Hispanic compared with 15% of non-caregivers (P < 0.05). Similar behavioral characteristics between caregivers and non-caregivers included daily alcohol consumption (6% vs. 5%) and lack of vigorous exercise (25% vs. 29%), but caregivers had a higher prevalence of smoking (26% vs. 19%, P < 0.05). Caregivers reported a higher mean percentage of work time missed (8% vs. 4%, P < 0.05) and greater productivity impairment (24% vs. 14%, P < 0.05). Some form of depression was reported by 53% of caregivers compared with 32% of non-caregivers (P < 0.05), and more caregivers had self-reported insomnia than non-caregivers (46% vs. 37%, P < 0.05). The number of self-reported diagnosed comorbidities was higher among caregivers compared with that of non-caregivers (5.0 vs. 3.1, P < 0.05), as was the mean number of outpatient visits in the previous 6months (4.1 vs. 2.7, P < 0.05). Conclusion: Family caregiving is associated with a multidimensional burden that impacts caregivers and has implications for employers and the health care system. Clinicians and employers need to recognize and understand this burden. Characterization of caregivers as reported in this study can inform development of targeted programs to help mitigate the burden. Keywords: caregiver burden, productivity, mental health, health care resource use, workforce, employed, family caregivers

BACKGROUND Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group. METHODS A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months. RESULTS Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9–10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC. CONCLUSION The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally. CLINICAL TRIALS REGISTRATION Trial Number NCT01918891.

OBJECTIVES: To estimate the health care resource use (HCRU) and costs for patients diagnosed with acromegaly, following treatment with either pegvisomant, a growth hormone receptor antagonist (GHRA); or a somatostatin analogue (SSA). METHODS: De-identified data from Optum’s ClinformaticsTM Data Mart (CDM), a US claims database, were used to retrospectively identify patients with acromegaly from January 2011 - June 2018 who were treated with the GHRA or an SSA. Propensity score matching (PSM) was used to address the small sample size of acromegaly patients and to ensure a direct comparison between the two treatment groups. PSM was fitted using a logistic regression model that included age, gender, total cost and Charlson Comorbidity Index (CCMI) score at index¹. Follow up (FU), HCRU (including Emergency Room [ER] costs, outpatient and inpatient costs) were compared. Average differences in change from baseline costs between the GHRA and SSA from the matched groups are shown with p-values obtained from a t-test. All costs are average across visits. RESULTS: Following PSM 91 patients were treated with GHRA and 269 patients were treated with SSAs. Mean ER costs were higher in the SSA vs GHRA group ($63 vs -$19, p=0.5646). On average outpatient visits were higher in the SSA vs GHRA group (2.88 and 2.82 respectively, p=0.8583); associated costs were higher ($1181 and $789 respectively p=0.3832). Regarding office visits and associated costs, these were also higher in the SSA group (Visit: 0.77 vs 0.74 and Cost: $1 vs -$7). The number of inpatient visits was equal (average =0.03) for both groups, with slightly higher costs in the GHRA group ($131 vs $161, p=0.9644). The drug cost and overall total cost of SSAs vs GHRA were significantly different ($2630 vs $6933, p

Background Homecare settings across the United States provide care to more than 5 million patients every year. About one in five homecare patients are rehospitalized during the homecare episode, with up to two-thirds of these rehospitalizations occurring within the first 2 weeks of services. Timely allocation of homecare services might prevent a significant portion of these rehospitalizations. The first homecare nursing visit is one of the most critical steps of the homecare episode. This visit includes an assessment of the patient’s capacity for self-care, medication reconciliation, an examination of the home environment, and a discussion regarding whether a caregiver is present. Hence, appropriate timing of the first visit is crucial, especially for patients with urgent health care needs. However, nurses often have limited and inaccurate information about incoming patients, and patient priority decisions vary significantly between nurses. We developed an innovative decision support tool called Priority for the First Nursing Visit Tool (PREVENT) to assist nurses in prioritizing patients in need of immediate first homecare nursing visits. Objective This study aims to evaluate the effectiveness of the PREVENT tool on process and patient outcomes and to examine the reach, adoption, and implementation of PREVENT. Methods Employing a pre-post design, survival analysis, and logistic regression with propensity score matching analysis, we will test the following hypotheses: compared with not using the tool in the preintervention phase, when homecare clinicians use the PREVENT tool, high-risk patients in the intervention phase will (1) receive more timely first homecare visits and (2) have decreased incidence of rehospitalization and have decreased emergency department use within 60 days. Reach, adoption, and implementation will be assessed using mixed methods including homecare admission staff interviews, think-aloud observations, and analysis of staffing and other relevant data. Results The study research protocol was approved by the institutional review board in October 2019. PREVENT is currently being integrated into the electronic health records at the participating study sites. Data collection is planned to start in early 2021. Conclusions Mixed methods will enable us to gain an in-depth understanding of the complex socio-technological aspects of the hospital to homecare transition. The results have the potential to (1) influence the standardization and individualization of nurse decision making through the use of cutting-edge technology and (2) improve patient outcomes in the understudied homecare setting. Trial Registration ClinicalTrials.gov NCT04136951; https://clinicaltrials.gov/ct2/show/NCT04136951 International Registered Report Identifier (IRRID) PRR1-10.2196/20184

Objectives: Urinary tract infection (UTI) is common in home care but not easily captured with standard assessment. This study aimed to examine the value of nursing notes in detecting UTI signs and symptoms in home care. Design: The study developed a natural language processing (NLP) algorithm to automatically identify UTI-related information in nursing notes. Setting and Participants: Home care visit notes (n = 1,149,586) and care coordination notes (n = 1,461,171) for 89,459 patients treated in the largest nonprofit home care agency in the United States during 2014. Measures: We generated 6 categories of UTI-related information from literature and used the Unified Medical Language System (UMLS) to identify a preliminary list of terms. The NLP algorithm was tested on a gold standard set of 300 clinical notes annotated by clinical experts. We used structured Outcome and Assessment Information Set data to extract the frequency of UTI-related emergency department (ED) visits or hospitalizations and explored time-patterns in documentation of UTI-related information. Results: The NLP system achieved very good overall performance (F measure = 0.9, 95% CI: 0.87–0.93) based on the test results obtained by using the notes for patients admitted to the ED or hospital due to UTI. UTI-related information was significantly more prevalent (P < .01 for all the tests) in home care episodes with UTI-related ED admission or hospitalization vs the general patient population; 81% of home care episodes with UTI-related hospitalization or ED admission had at least 1 category of UTI-related information vs 21.6% among episodes without UTI-related hospitalization or ED admission. Frequency of UTI-related information documentation increased in advance of UTI-related hospitalization or ED admission, peaking within a few days before the event. Conclusions and Implications: Information in nursing notes is often overlooked by stakeholders and not integrated into predictive modeling for decision-making support, but our findings highlight their value in early risk identification and care guidance. Health care administrators should consider using NLP to extract clinical data from nursing notes to improve early detection and treatment, which may lead to quality improvement and cost reduction.

Aim: Assess the comparative effectiveness of two blood pressure (BP) control interventions for black patients with uncontrolled hypertension. Patients & methods: A total of 845 patients were enrolled in a three-arm cluster randomized trial. On admission of an eligible patient, field nurses were randomized to usual care, a basic or augmented intervention. Results: Across study arms there were no significant 12 months differences in BP control rates (primary outcome) (25% usual care, 26% basic intervention, 22% augmented intervention); systolic BP (143.8 millimeters of mercury [mmHg], 146.9 mmHG, 143.9 mmHG, respectively); medication intensification (47, 43, 54%, respectively); or self-management score (18.7, 18.7, 17.9, respectively). Adjusted systolic BP dropped more than 10 mmHg from baseline to 12 months (155.5–145.4 mmHg) among all study participants. Conclusion: Neither the augmented nor basic intervention was more effective than usual care in improving BP control, systolic BP, medication intensification or patient self-management. Usual home care yielded substantial improvements, creating a high comparative effectiveness threshold. Clinical Trial Registration: NCT00139490.

Background: Urinary tract infection and blockage are serious and recurrent challenges for people with long-term indwelling catheters, and these catheter problems cause worry and anxiety when they disrupt normal daily activities. Objective: The goal was to determine whether urinary catheter-related self-management behaviors focusing on fluid intake would mediate fluid intake-related self-efficacy toward decreasing catheter-associated urinary tract infection (CAUTI) and/or catheter blockage. Methods: The sample involved data collected from 180 adult community-living, long-term indwelling urinary catheter users. The authors tested a model of fluid intake self-management related to fluid intake self-efficacy for key outcomes of CAUTI and blockage. To account for the large number of zeros in both outcomes, a zero-inflated negative binomial (ZINB) structural equation model was tested. Results: Structurally, fluid intake self-efficacy was positively associated with fluid intake self-management, suggesting that higher fluid intake self-efficacy predicts more (higher) fluid intake self-management; however, fluid intake self-management was not associated with either the frequency of CAUTIs or the presence or absence of CAUTI. Fluid intake self-efficacy was positively related to fluid intake self-management, and fluid intake self-management predicted less frequency of catheter blockage, but neither fluid intake self-efficacy nor fluid intake self-management predicted the presence or absence of blockage. Discussion: Further research is needed to better understand determinants of CAUTI in long-term catheter users and factors which might influence or prevent its occurrence. Increased confidence (self-efficacy) and self-management behaviors to promote fluid intake could be of value to long-term urinary catheter users to decrease catheter blockage.

Efficient and appropriate recruitment and retention of study participants is essential to collecting valid data for rigorous quality of life research for America’s aging population. Recruitment and retention of racially/ethnically diverse, physically ill older adults to randomized controlled trials (RCTs) can be particularly challenging. This paper will identify socio-demographic, clinical, behavioral, and attitudinal factors that affected recruitment and retention of black and Latino post-stroke patients with uncontrolled hypertension to an RCT that tested the effectiveness of a three-month nurse practitioner and health coach intervention to reduce patients’ systolic blood pressure and related risk of recurrent stroke. This paper will also showcase the dynamic, sometimes unconventional methods employed to address recruitment/retention barriers. Data were drawn from a population of 5858 potentially eligible study participants, of whom 495 (8.4%) enrolled in the RCT (345 black and 150 Latino individuals). Data were collected during an initial telephone screen, an enrollment interview (baseline), a 3-month follow-up interview, and a 12-month follow-up interview. Over 30% of the potentially eligible patients agreed to participate after the telephone screen and, among the 495 enrolled participants, high retention rates were achieved at both the 3-month (87%) and 12-month (81%) follow-up interviews. Participants were equally likely to complete the 3- and 12-month follow-up interviews whether they were in a control or treatment group. Successful recruitment and retention strategies were those that were flexible to the participant’s individual needs, culturally tailored to the target population, and implemented by a well-trained workforce. Implications for future studies will be discussed.

Significant racial and ethnic disparities in stroke risk factors, occurrence and outcomes persist in the United States. This article examines socio-economic and health disparities in a diverse, hypertensive sample of 495 post-stroke Black, non-Hispanic and Hispanic home health patients at risk of a recurrent stroke due to elevated systolic blood pressure (SBP), defined as SBP ≥ 140 mmHg. The article, which analyzes cross-sectional data, focuses on correlates of patients’ SBP – the leading modifiable cause of stroke – and physical function – a key stroke sequela and indicator of post-stroke quality of life. Of the 495 participants, 69.7% were Black, non-Hispanic, and 30.3% Hispanic. Black participants had significantly higher mean SBP than Hispanics. After controlling for multiple potential confounders/predictors, being Black was associated with a 3.55 mmHg elevation in SBP relative to being Hispanic. There were no significant Black/Hispanic differences in physical function measures. Seven independent variables significantly predicted better physical function: being male, younger, having fewer comorbidities, lower BMI, fewer depressive symptoms, higher health literacy and current alcohol drinking (vs abstinence). Our data provide a unique comparison of homebound Black and Hispanic stroke survivors at heightened risk of recurrent stroke absent targeted intervention. The finding of a significant Black/Hispanic disparity in SBP is striking in this narrowly defined home health care population all of whom are at risk for recurrent stroke. Priority should be given to culturally tailored interventions designed to link vulnerable home care patients to continuous, responsive hypertension care.

Background Natural language processing (NLP) of health-related data is still an expertise demanding, and resource expensive process. We created a novel, open source rapid clinical text mining system called NimbleMiner. NimbleMiner combines several machine learning techniques (word embedding models and positive only labels learning) to facilitate the process in which a human rapidly performs text mining of clinical narratives, while being aided by the machine learning components. Objective This manuscript describes the general system architecture and user Interface and presents results of a case study aimed at classifying fall-related information (including fall history, fall prevention interventions, and fall risk) in homecare visit notes. Methods We extracted a corpus of homecare visit notes (n = 1,149,586) for 89,459 patients from a large US-based homecare agency. We used a gold standard testing dataset of 750 notes annotated by two human reviewers to compare the NimbleMiner’s ability to classify documents regarding whether they contain fall-related information with a previously developed rule-based NLP system. Results NimbleMiner outperformed the rule-based system in almost all domains. The overall F- score was 85.8% compared to 81% by the rule based-system with the best performance for identifying general fall history (F = 89% vs. F = 85.1% rule-based), followed by fall risk (F = 87% vs. F = 78.7% rule-based), fall prevention interventions (F = 88.1% vs. F = 78.2% rule-based) and fall within 2 days of the note date (F = 83.1% vs. F = 80.6% rule-based). The rule-based system achieved slightly better performance for fall within 2 weeks of the note date (F = 81.9% vs. F = 84% rule-based). Discussion & conclusions NimbleMiner outperformed other systems aimed at fall information classification, including our previously developed rule-based approach. These promising results indicate that clinical text mining can be implemented without the need for large labeled datasets necessary for other types of machine learning. This is critical for domains with little NLP developments, like nursing or allied health professions.

Aims Self-management is believed to be an important behavioral capacity in people with chronic illness, and self-efficacy is an important component contributing to self-management. Two new and related measures for urinary catheter self-efficacy (C-SE) and self-management (C-SMG) were developed based on existing tools and tested for psychometrics for use in a randomized clinical trial (RCT) teaching urinary catheter self-management. Methods The instruments were evaluated at baseline (intake face to face interview) with 202 persons and with 158 of the same individuals 6 months later by telephone interviews. Exploratory factor analysis was conducted in an iterative process related to items’ theoretical and statistical appropriateness. To assess construct validity and goodness of fit for model testing, confirmatory factor analysis was conducted with the samples at intake and 6 months. Also, bivariate analyses were conducted of the measures in relation to each other. Results Both scales were modified reducing the items to 13 in each, with four factors in C-SE and three factors in C-SMG. Reliability testing (Cronbach's alpha) was viewed as satisfactory for both scales, though some of the subscale (factors) reliabilities were lower in the self-management measure. Confirmatory factor analysis was adequate. Correlation of the two instruments (r = 0.25, P

Effective screening and recruitment are essential to the success of randomized clinical trials. This report is to describe key screening and recruitment strategies in a two site randomized clinical trial (RCT) conducted in community settings with a vulnerable chronically ill population and to suggest valuable approaches when planning trials. Differences between sites in a complex study with two considerably different environments (academic versus home care) and their participant pools presented challenges which required different screening and recruitment methods. A high level of communication between sites, creative problem solving and the ability to be flexible when problems were encountered were needed for successful screening and recruitment.

A long-term indwelling urinary catheter intervention was tested in a randomized trial that is described in this article. The perceived value of the intervention to the catheter users, one of the study’s specific aims, was assessed at the end of their 12-month participation and is reported here. Study participants’ responses, our findings, and implications for home healthcare are discussed.

To characterise a sample of 202 adult community-living long-term indwelling urinary catheter users, to describe self-care practices and catheter problems, and to explore relationships among demographics, catheter practices and problems.Long-term urinary catheter users have not been well studied, and persons using the device indefinitely for persistent urinary retention are likely to have different patterns of catheter practices and problems.The study was a cross-sectional descriptive and exploratory analysis.Home interviews were conducted with catheter users who provided information by self-reported recall over the previous two months. Data were analysed by descriptive statistics and tests of association between demographics, catheter practices and catheter problems.The sample was widely diverse in age (19-96 years), race and medical diagnosis. Urethral catheters were used slightly more often (56%) than suprapubic (44%), for a mean of six years (SD 7 years). Many persons were highly disabled, with 60% having difficulty in bathing, dressing, toileting and getting out of the bed; 19% also required assistance in eating. A high percentage of catheter problems were reported with: 43% experiencing leakage (bypassing of urine), 31% having had a urinary tract infection, 24% blockage of the catheter, 23% catheter-associated pain and 12% accidental dislodgment of the catheter. Treatments of catheter-related problems contributed to additional health care utilisation, including extra nurse or clinic visits, trips to the emergency department or hospitalisation. Symptoms of catheter-associated urinary tract infections were most often related to changes in the colour or character of urine or generalised symptoms.Catheter-related problems contribute to excess morbidity and health care utilisation and costs.More research is needed in how to minimise catheter-associated problems in long-term catheter users. Information from this study could help inform the development of interventions in this population.

Objective To adapt and automate the medication regimen complexity index (MRCI) within the structure of a commercial medication database in the post-acute home care setting. Materials and Methods In phase 1, medication data from 89 645 electronic health records were abstracted to line up with the components of the MRCI: dosage form, dosing frequency, and additional administrative directions. A committee reviewed output to assign index weights and determine necessary adaptations. In phase 2 we examined the face validity of the modified MRCI through analysis of automatic tabulations and descriptive statistics. Results The mean number of medications per patient record was 7.6 (SD 3.8); mean MRCI score was 16.1 (SD 9.0). The number of medications and MRCI were highly associated, but there was a wide range of MRCI scores for each number of medications. Most patients (55%) were taking only oral medications in tablet/capsule form, although 16% had regimens with three or more medications with different routes/forms. The biggest contributor to the MRCI score was dosing frequency (mean 11.9). Over 36% of patients needed to remember two or more special instructions (eg, take on alternate days, dissolve). Discussion Medication complexity can be tabulated through an automated process with some adaptation for local organizational systems. The MRCI provides a more nuanced way of measuring and assessing complexity than a simple medication count. Conclusions An automated MRCI may help to identify patients who are at higher risk of adverse events, and could potentially be used in research and clinical decision support to improve medication management and patient outcomes.

To address the gap in knowledge about the impact of chronic obstructive pulmonary disease (COPD) on older working adults, this study examined quality of life, worker productivity, and healthcare resource utilization among employed adults aged 65 and older with and without COPD. Among 2009 National Health and Wellness Survey (a cross-sectional, internet-based survey representative of the US adult population) respondents, employed adults aged 65 years and older, with COPD (n = 297) and without COPD (n = 3061), were included in analyses. Impact of self-reported COPD diagnosis on mean quality of life (using health utilities and mental, MCS, and physical, PCS, component summary scores from SF-12v2), work productivity and activity impairment (using the WPAI questionnaire), and resource use were examined. Adjusting for demographic and health characteristics such as co-morbidities (weighted to project to the US population) in regression models (linear, negative binomial, or logistic, as appropriate given the outcome measure), older workers with COPD reported significantly lower MCS (52.1 vs. 53.4, p < .05), PCS (40.3 vs. 47.2, p < .05), and health utilities (0.72 vs. 0.79, p < .05) than those without COPD, and significantly greater percentages of impairment while at work (presenteeism) (12.6% vs. 8.7%, p < .0001), overall work impairment (absenteeism and presenteeism combined) (19.3% vs. 10.0%, p < .05), and impairment in daily activities (23.9% vs. 13.7%, p < .05). There were no significant differences in absenteeism or healthcare use. Quality of life and work productivity suffered among employed adults aged 65 years and older with COPD, emphasizing the need for disease management in this population.

HYPERTENSION, dyslipidemia, and diabetes are established risk factors for cardiovascular disease (CVD) morbidity and mortality (1). Adults aged 65 and older are disproportionately affected by these factors, and although they make up only 12% of the total United States (U.S.) population, they incur 62% of national health care expenses for heart conditions (2,3). CVD risk reduction strategies among older adults can lead to a decline in premature CVD morbidity and mortality (4–7). However, the past decade has shown a general increase in CVD risk factors in this population along with suboptimal control rates. CVD mortality remains the number one cause of death among adults aged 65 and older, accounting for 31% of all deaths in this age group in 2003 (8–11). The prevalence and management (treatment and control) of cardiovascular risk factors among elderly people aged 65 and older has not been well described, yet this population will nearly double from 37 million in 2005 to 72 million in 2030 (2,12) presenting challenges to the Centers for Medicare and Medicaid Services, which provides the primary health insurance program, Medicare, to most of these adults. Knowledge of the current magnitude of hypertension, dyslipidemia, and diabetes in this population is important for health care resource allocation, disease management, and education (13,14). The National Health and Nutrition Examination Survey (NHANES) is a nationally representative survey of noninstitutionalized adults providing data on a wide variety of health conditions through in-person interviews at home, followed by clinical examinations and laboratory tests in a mobile examination center (15). This study presents national-level data from the NHANES 1999–2004 to estimate the prevalence, awareness, pharmacologic treatment, and control of hypertension, dyslipidemia, and diabetes among adults 65 years of age and older. A number of publications have used the NHANES 2003–2004 data to report on aspects of hypertension, high cholesterol, or diabetes in selected subpopulations; however, these have not specifically addressed awareness, treatment, and control in adults aged 65 and older (8,9,16–19). Our study updates the current literature with analyses of these three cardiovascular risk factors, combining the NHANES 2003–2004 with the NHANES 1999–2002 data in order to present a more robust sample. Prevalence estimates in this study are based on clinical examination rather than self-reported data; therefore, prevalence rates for each condition include diagnosed and undiagnosed disease. We also present predictors of awareness, treatment, and control for these three CVD risk factors.

Rationale, aims and objectives To assess the outcomes of a clinical decision support (CDS) intervention designed for home care patients with high medication regimen complexity (MRC) and to examine correlates of CDS use. Method The CDS consisted of a computerized algorithm that identified high MRC patients, electronic alerts and a care management module. Nurses were randomized upon identification of an eligible patient. Full intention to treat and intervention group-only analyses were completed. Regression-adjusted outcomes were hospitalization, emergency department use and reduction in MRC. Results Five hundred nurses were randomized with 7919 of their patients. Approximately 20% of the intervention group was hospitalized versus 21% in the control group; 16.5% versus 16.7% had an emergency department visit; and 6% in each group dropped below the high MRC threshold. No statistically significant differences were found in the intention to treat analysis. Eighty-two percent of intervention nurses used the CDS but for only 42% of their patients. Among intervention patients, CDS use (vs. non-use) was associated with reduced MRC and hospitalization. CDS use was associated with various clinician and patient characteristics. Conclusion CDS use was limited, negating the impact of the intervention overall. Findings on correlates of CDS use and the relationship between CDS use and positive outcomes suggest that CDS use and outcomes could be enhanced by avoiding short patient lengths of stay, improving continuity of care, increasing reliance on salaried nurses and/or increasing per diem nurses' incentives to use CDS.

Background: People using long-term indwelling urinary catheters experience multiple recurrent catheter problems. Self-management approaches are needed to avoid catheter-related problems. Objectives: The aim was to determine effectiveness of a self-management intervention in prevention of adverse outcomes (catheter-related urinary tract infection, blockage, and accidental dislodgement). Healthcare treatment associated with the adverse outcomes and catheter-related quality of life was also studied. Methods: A randomized clinical trial was conducted. The intervention involved learning catheter-related self-monitoring and self-management skills during home visits by a study nurse (twice during the first month and at 4 months—with a phone call at 2 months). The control group received usual care. Data were collected during an initial face-to-face home interview followed by bimonthly phone interviews. A total of 202 adult long-term urinary catheter users participated. Participants were randomized to treatment or control groups following collection of baseline data. Generalized estimating equations were used for the analysis of treatment effect. Results: In the intervention group, there was a significant decrease in reported blockage in the first 6 months (p = .02), but the effect did not persist. There were no significant effects for catheter-related urinary tract infection or dislodgment. Comparison of baseline rates of adverse outcomes with subsequent periods suggested that both groups improved over 12 months. Discussion: A simple-to-use catheter problems calendar and the bimonthly interviews might have functioned as a modest self-monitoring intervention for persons in both groups. A simplified intervention using a self-monitoring calendar is suggested—with optimal and consistent fluid intake likely to add value.

African-Americans (AAs) have a high prevalence of hypertension and their blood pressure (BP) control on treatment still lags behind other groups. In 2004, NHLBI funded five projects that aimed to evaluate clinically feasible interventions to effect changes in medical care delivery leading to an increased proportion of AA patients with controlled BP. Three of the groups performed a pooled analysis of trial results to determine: 1) the magnitude of the combined intervention effect; and 2) how the pooled results could inform the methodology for future health-system level BP interventions.Using a cluster randomized design, the trials enrolled AAs with uncontrolled hypertension to test interventions targeting a combination of patient and clinician behaviors. The 12-month Systolic BP (SBP) and Diastolic BP (DBP) effects of intervention or control cluster assignment were assessed using mixed effects longitudinal regression modeling.2,015 patients representing 352 clusters participated across the three trials. Pooled BP slopes followed a quadratic pattern, with an initial decline, followed by a rise toward baseline, and did not differ significantly between intervention and control clusters: SBP linear coefficient = -2.60±0.21 mmHg per month, p0.001; quadratic coefficient = 0.167± 0.02 mmHg/month, p0.001; group by time interaction group by time group x linear time coefficient=0.145 ± 0.293, p=0.622; group x quadratic time coefficient= -0.017 ± 0.026, p=0.525). RESULTS were similar for DBP. The individual sites did not have significant intervention effects when analyzed separately.Investigators planning behavioral trials to improve BP control in health systems serving AAs should plan for small effect sizes and employ a "run-in" period in which BP can be expected to improve in both experimental and control clusters.

A process fidelity assessment was conducted as a nested study within a home-based randomized clinical trial teaching self-management to 101 long-term indwelling urinary catheter users in the treatment group. Our hybrid model combined external assessments (outside observations and tape recordings) with internal evaluation methods (through study nurse forms and notes) for a comprehensive process fidelity assessment. Barriers, patient-related issues, and nurse perspectives were identified demonstrating the complexity in home care intervention research. The complementary and synergistic approaches provided in-depth information about the context of the delivery and the impact of the intervention on study outcomes.