Search

Urinary tract infections (UTIs) are one of the most common infections in older people and are associated with increased morbidity and mortality. UTIs are also associated with increased risk of antimicrobial resistance (AR). This study examined changes in AR among older inpatients with a primary diagnosis of UTIs in the United States over an 8-year period and the impact of AR on clinical outcomes and hospital costs. Data were obtained from the longitudinal hospital HCUP-NIS database from 2009 to 2016 for inpatient episodes that involved those aged 65+ years. The ICD-9 and ICD-10 codes were used to identify episodes with a primary diagnosis of UTIs, comorbidities, AR status and age-adjusted Deyo-Charlson comorbidity index (ACCI) for the patient concerned. Weighted multivariable regression was used to examine the impact of AR on all-cause inpatient mortality, discharge destination, length of stay and hospital expenditures, adjusted for socio-demographic and clinical covariates. The proportion of admissions with AR increased, from 3.64% in 2009 to 6.88% in 2016 (p<0.001), with distinct patterns for different types of resistance. The likelihood of AR was higher in admissions with high ACCI scores and admissions to hospitals in urban areas. Admissions with AR were more likely to be discharged to healthcare facilities (e.g. care homes) compared to routine discharge (OR 1.81; 95%CI, 1.75–1.86), had increased length of stay (1.12 days; 95%CI, 1.06–1.18) and hospital costs (1259 USD; 95%CI, 1178–1340). Resistance due to MRSA was specifically associated with increased hospital mortality (OR 1.33; 95%CI, 1.15–1.53). Our findings suggest that the prevalence of AR has increased among older inpatients with UTIs in the USA. The study highlights the impact of AR among older inpatients with a primary diagnosis of UTIs on clinical outcomes and hospital costs. These relationships and their implications for the care homes to which patients are frequently discharged warrant further research. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To quantify the association between including specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes and the prevalence of use. DESIGN: Quasi-experimental. SETTING: One thousand one hundred forty-one nursing homes in four U.S. states. PARTICIPANTS: Residents living in one of the included nursing homes in operation during 1997 (before Beers; n=130,250) and 2000 (after Beers; n=164,889). INTERVENTION: Inclusion of specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes. MEASUREMENTS: Logistic regression models adjusting for clustering effects of residents residing in homes provided estimates of the relationship between the survey process and use of any medications targeted as potentially inappropriate as part of the survey process, as well as those deemed inappropriate but not included. RESULTS: The use of any potentially inappropriate medication decreased from 42.5% in 1997 to 39.8% in 2000. After adjustment for resident characteristics, residents were less likely to receive any potentially inappropriate medication (odds ratio (OR)=0.85, 95% confidence interval (95% CI)=0.84–0.87), those considered high-severity drugs (those with a high likelihood of a clinically significant adverse event) (OR=0.67, 95% CI=0.65–0.69), or Beers' medications not included in the surveyors' guidelines (OR=0.76, 95% CI=0.74–0.79) in 2000 than in 1997 after the changes to the drug regulations and interpretive guidelines. CONCLUSION: Targeting specific drugs in the surveyor's interpretive guidelines as a method to reduce potentially inappropriate medication use may not produce desired gains in medication-use quality improvement. Alternative strategies for nursing homes should be evaluated. [ABSTRACT FROM AUTHOR]

Background: Since 1998, a prospective payment system (PPS) for Medicare services provided by nursing homes in the US has been in operation. Concerns have been expressed that the PPS may affect the quality of care delivered to residents. This study evaluates the impact of the PPS on pharmacological secondary ischaemic stroke prevention in nursing homes. Study design: The nationally mandated Minimum Data Set and Online Survey Certification and Automated Record data system from 1997 and 2000 for four states were used. We conducted a quasi-experimental study comparing the pharmacological treatment rates for secondary stroke prevention in the pre-PPS period (1997) with those in the post-PPS period (2000) in residents who experienced an ischaemic stroke within 6 months (n1997 = 5008; n2000 = 5243) of living in nursing facilities (n1997 = 1226; n2000 = 1092) in Kansas, Maine, Mississippi or Ohio. The sample was stratified according to recommendations for use of warfarin. Logistic regression models adjusting for clustering effects of residents residing in homes using generalised estimating equations provided estimates of the PPS effect on use of antiplatelets and the use of warfarin. Results: The unadjusted proportion of use of pharmacological agents for the secondary prevention of stroke was similar for warfarin in both time periods and increased for antiplatelets in 2000. Relative to the pre-PPS era, the likelihood of use of antiplatelets increased in the post-PPS era (adjusted odds ratio 1.26; 95% CI 1.15, 1.38); there was no effect on the use of warfarin. Conclusion: Although the lack of a PPS effect on pharmacological management of secondary ischaemic stroke is encouraging, there is still room for improvement in overall stroke management. [ABSTRACT FROM AUTHOR]

Summarizes the United States' Nursing Reform Act of 1987 in respect of prescribing, implementation and influence on nursing home care delivery and consider alternative approaches for Great Britain. Significance of the Omnibus Budget Reconciliation Act of 1987; Impact of legislation on prescribing patient's drug; Legislation on nursing homes in Great Britain.

Background: Little is known about the attitudes of healthcare professional students' perceived competence and confidence in treating those with dementia who are at the end of life., Aim: To explore the attitudes of final year medical, nursing and pharmacy students towards people with dementia and to evaluate their perceived competence and confidence dealing with biomedical and psychosocial issues within the context of palliative care provision to patients with dementia., Design: Cross-sectional survey using a questionnaire., Setting/participants: Final-year students in each profession from Queen's University Belfast (Northern Ireland) and the University of Iowa (USA) were recruited., Method: Three versions of an online questionnaire (containing the Attitudes to Dementia Questionnaire and a series of questions on end-of-life care in dementia) were distributed., Results: A total of 368 responses were received (response rate 42.3%). All respondents reported positive attitudes towards people with dementia. US nursing students reported significantly more positive attitudes than the medical students of United States and Northern Ireland. Medical students were more likely to report low confidence in discussing non-medical aspects of dying, whereas nursing students were most likely to feel prepared and confident to do this. Medical and nursing students reported low confidence with aspects of medication-related care; however, data from the pharmacy samples of Northern Ireland and United States suggested that these students felt confident in advising other healthcare professionals on medication-related issues., Conclusions: While healthcare students hold positive attitudes towards people with dementia, some clinical tasks remain challenging and further basic training may be of benefit.

Objectives: To evaluate the cost-effectiveness of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood NI Study)., Design: Economic evaluation alongside a cluster randomized controlled trial., Setting: Nursing homes in NI randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11)., Participants: Residents aged 65 and older who provided informed consent (N=253; 128 intervention, 125 control) and who had full resource use data at 12 months., Intervention: Trained pharmacists reviewed intervention home residents' clinical and prescribing information for 12 months, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to make changes. The control homes received usual care in which there was no pharmacist intervention., Measurements: The proportion of residents prescribed one or more inappropriate psychoactive medications (according to standardized protocols), costs, and a cost-effectiveness acceptability curve. The latter two outcomes are the focus for this article., Results: The proportions of residents receiving inappropriate psychoactive medication at 12 months in the intervention and control group were 19.5% and 50.4%, respectively. The mean cost of healthcare resources used per resident per year was $4,923 (95% confidence interval (CI)=$4,206-5,640) for the intervention group and $5,053 (95% CI=$4,328-5,779) for the control group. The probability of the intervention being cost-effective was high, even at low levels of willingness to pay to avoid a resident receiving inappropriately prescribed psychoactive medication., Conclusion: The Fleetwood NI model of care was more cost-effective than usual care., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Objectives: To test the effect of an adapted U.S. model of pharmaceutical care on prescribing of inappropriate psychoactive (anxiolytic, hypnotic, and antipsychotic) medications and falls in nursing homes for older people in Northern Ireland (NI)., Design: Cluster randomized controlled trial., Setting: Nursing homes randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11)., Participants: Residents aged 65 and older who provided informed consent (N=334; 173 intervention, 161 control)., Intervention: Specially trained pharmacists visited intervention homes monthly for 12 months and reviewed residents' clinical and prescribing information, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to improve the prescribing of these drugs. The control homes received usual care., Measurements: The primary end point was the proportion of residents prescribed one or more inappropriate psychoactive medicine according to standardized protocols; falls were evaluated using routinely collected falls data mandated by the regulatory body for nursing homes in NI., Results: The proportion of residents taking inappropriate psychoactive medications at 12 months in the intervention homes (25/128, 19.5%) was much lower than in the control homes (62/124, 50.0%) (odds ratio=0.26, 95% confidence interval=0.14-0.49) after adjustment for clustering within homes. No differences were observed at 12 months in the falls rate between the intervention and control groups., Conclusion: Marked reductions in inappropriate psychoactive medication prescribing in residents resulted from pharmacist review of targeted medications, but there was no effect on falls.

Objective: To provide normative information regarding levels of job satisfaction and stress between consulting and dispensing pharmacists in the long-term care arena., Design: Cross-sectional., Setting: United States., Participants: All current members of the American Society of Consultant Pharmacists as of March 2005., Interventions: None., Main Outcome Measure: Health Professional Stress Inventory., Results: More than 90% of consultant pharmacists were satisfied with their jobs. The most frequently reported source of stress among the pharmacists was short staffing, affecting their ability to perform their duties. More than one-third of dispensing pharmacists were often stressed, frequently because of the need to keep up with developments to maintain professional competence., Conclusion: Pharmacists serving the long-term care sector are very satisfied. Methods to assist dispensing pharmacists to keep up with practice developments must be explored. Whether or not new models of long-term care pharmacy improve job satisfaction must be explored.

Background: There is universal agreement that organizational characteristics of nursing facilities can and do influence the quality of care and resident outcomes., Objective: This study evaluated the relation between organizational characteristics and management of depression using antidepressants., Research Design: This was a cross-sectional study of Medicare/Medicaid certified nursing homes in 6 states in 2000., Subjects: We studied 87,907 residents with depression in 2,128 facilities., Measures: Minimum Data Set (MDS) provided information regarding use of antidepressants and resident factors. On-line Survey and Certification of Automated Records (OSCAR) provided facility characteristics information including structural, resource, and staffing levels. Adjusted estimates of organizational effects on antidepressant drug use were derived from generalized estimating equations., Results: Increased treatment of depression with antidepressants was associated with facilities with a higher percentage of residents from payer sources other than Medicare/Medicaid (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06) and more professional nursing staff (OR, 1.15; 95% CI, 1.05-1.26). Decreased treatment tended to be related to larger homes (OR, 0.76; 95% CI, 0.68-0.84) or if the home employed full-time physicians (OR, 0.87; 95% CI, 0.78-0.96). Once the decision to treat was made, treatment with tricyclics tended to be inversely related to larger homes, for-profit facilities, and homes with more Medicare residents., Conclusions: Facilities that are required to be more fiscally conservative, be it larger facilities with fewer private pay patients or for profit facilities, have lower rates of pharmacologic treatment. Resource and structural characteristics influence the type of antidepressant being prescribed; resident characteristics may not be the over-riding factor in prescribing.

The quality of nursing home care has often given rise to concern from many interested stakeholders. In the US, this has led to the implementation of a major legislative framework in the form of the Nursing Home Reform Act, which sought to improve the quality of care through regulation and inspections. Research has shown that certain elements of care have improved but much remains to be done. Additional pressure is now being placed on the nursing home sector through the introduction of a prospective payment system (PPS), which sets limits on reimbursement for services for Medicare-covered stays. It has been proposed that this new system of payment may lead to difficulties in accessing nursing home care for patients who are deemed to be costly, and initial assessments suggest that patients are now carefully screened before being admitted to nursing homes. This may have major implications for patients who require multiple and expensive drug therapy and other interventions. Although the Nursing Home Reform Act seeks to drive forward the quality agenda in nursing home care, research is urgently required to evaluate the impact of the PPS which may force this healthcare sector to emphasise reducing costs at the expense of residents' needs.