Research Interests:
Research Interests:
Research Interests:
Background Assessing chronic obstructive pulmonary disease (COPD) severity is challenging in nursing home (NH) residents due to incomplete symptom assessments and exacerbation history. Objective The objective of this study was to predict... more
Background Assessing chronic obstructive pulmonary disease (COPD) severity is challenging in nursing home (NH) residents due to incomplete symptom assessments and exacerbation history. Objective The objective of this study was to predict COPD severity in NH residents using the Minimum Data Set (MDS), a clinical assessment of functional capabilities and health needs. Methods A cohort analysis of prospectively collected longitudinal data was conducted. Residents from geographically varied Medicare-certified NHs with age ≥60 years, COPD diagnosis, and ≥6 months NH residence at enrollment were included. Residents with severe cognitive impairment were excluded. Demographic characteristics, medical history, and MDS variables were extracted from medical records. The care provider–completed COPD Assessment Test (CAT) and COPD exacerbation history were used to categorize residents by Global Initiative for Chronic Lung Disease (GOLD) A to D groups. Multivariate multinomial logit models mapped the MDS to GOLD A to D groups with stepwise selection of variables. Results Nursing home residents (N = 175) were 64% women and had a mean age of 77.9 years. Among residents, GOLD B was most common (A = 13.1%; B = 44.0%; C = 5.7%; D = 37.1%). Any long-acting bronchodilator (LABD) use and any dyspnea were significant predictors of GOLD A to D groups. The predicted MDS-GOLD group (A = 6.9%; B = 52.6%; C = 4.6%; D = 36.0%) showed good model fit (correctly predicted = 60.6%). Nursing home residents may underuse group-recommended LABD treatment (no LABD: B = 53.2%; C = 80.0%; D = 40.0%). Conclusion and Relevance The MDS, completed routinely for US NH residents, could potentially be used to estimate COPD severity. Predicted COPD severity with additional validation could provide a map to evidence-based treatment guidelines and may help to individualize treatment pathways for NH residents.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Background Trauma patients older than 80 years of age have higher mortality rates compared to younger peers. No studies have investigated the effectiveness of geriatrics comanagement on mortality in general trauma. Methods A retrospective... more
Background Trauma patients older than 80 years of age have higher mortality rates compared to younger peers. No studies have investigated the effectiveness of geriatrics comanagement on mortality in general trauma. Methods A retrospective cohort study from 2015 to 2016 comparing overall and inpatient mortality in a geriatrics trauma comanagement (GTC) program versus usual care (UC). Demographic and outcome measures were obtained from the trauma registry at an 11-bed trauma critical care unit within a 719-bed Level 1 Trauma Center. One thousand five hundred and seventy two patients, 80 years and older, with an admitting trauma diagnosis were evaluated. Primary outcome was in-hospital mortality and overall mortality (defined as inpatient death or discharge to hospice). Secondary outcomes included hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, discharge location, and medical complications. Results Three hundred and forty six patients (22%) were placed in the GTC program. Overall mortality was lower in the GTC (4.9%) when compared with UC (11.9%), representing a 57% reduction (95% odds ratio [OR] confidence interval [CI] 0.24–0.75, p value = .0028). There was a 7.42% hospital mortality rate in the UC group compared to 2.6% in the GTC group (95% CI 0.21–0.92, p value = .0285), representing a 56% decrease in in-hospital mortality. GTC patients had a longer mean LOS (6.4 days vs 5.3 days, p value < .0001). More GTC patients were sent to inpatient rehabilitation facilities or skilled nursing facilities (80% vs 60%, p value < .0001). Conclusion Geriatrics trauma comanagement of trauma patients above the age of 80 may reduce mortality and deserves formal study.
Research Interests:
Research Interests:
Research Interests:
Research Interests: Adolescent, Medicine, Swimming, Humans, Pubmed, and 5 moreMale, Iron, Adult, Physical Endurance, and Stress Physiological
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
espiratory syncytial virus (RSV) is the most frequent R cause of lower respiratory tract illness in infants and young children. Early studies in adults indicated that RSV infection was associated with a mild illness resembling the common... more
espiratory syncytial virus (RSV) is the most frequent R cause of lower respiratory tract illness in infants and young children. Early studies in adults indicated that RSV infection was associated with a mild illness resembling the common cold.' Later studies, however, demonstrated that infection could be associated with significant morbidity, absenteeism, and prolonged alterations in airway resistance.' It has also been reported that RSV infection may cause severe or fatal pneumonia in adults immunocompromised as the result of organ transplantation, hematologic malignancy, or HIV in fe~t ion .~-~ In the last 15 years, a number of studies have also demonstrated that RSV infection may be associated with a clinically significant, influenza-like illness in residents of longterm care Early reports described several outbreaks of RSV infection that were investigated retrospectively after the onset of respiratory illness in a large number of resident~.'~~*''-'~ In general, the diagnosis of RSV was established serologically, and evidence of other respiratory viruses was not detected. Attack rates were high (19 to 43%), and the illnesses were of variable severity. In the most severe outbreak, 40 of 101 residents in a nursing home developed respiratory illness; among those who became ill, 55% developed radiographically proven pneumonia, and 20% died.13 Prospective studies of respiratory illnesses in nursing homes have also detected the presence of RSV infection. In most of these studies, RSV was implicated in a minority of i l l n e s ~ e s . ~ ~ ' ~ ~ ' ~ However, one recent study found RSV to be the predominant respiratory virus identified during an influenza season.'' In that study, 149 illnesses were studied in a 591-bed nursing home. Sixty-two illnesses were determined to be of viral etiology, and of these, 40 were attributed to RSV and only two to influenza. The same investigators evaluated acute and convalescent serum obtained from ill residents in two nursing homes." The proportion of ill residents with serologic evidence of RSV infection varied widely, from 3% in one nursing home to 20% in the second facility.
Research Interests:
To determine factors that might account for a significantly lower attack rate in a newly constructed nursing building during an epidemic of type A influenza. A four-building, long-term care facility for veterans and their spouses, with an... more
To determine factors that might account for a significantly lower attack rate in a newly constructed nursing building during an epidemic of type A influenza. A four-building, long-term care facility for veterans and their spouses, with an average daily census of 690. Prospective surveillance with retrospective analysis. Symptomatic residents submitting to viral culture. Number of respiratory illnesses and influenza cultures in consenting symptomatic residents. Building characteristics. An influenza A (H3N2) outbreak was culture-confirmed in 68 nursing home residents. Influenza A was isolated in 3/184 (2%) residents in Building A, 31/196 (16%) in Building B, 18/194 (9%) in Building C, and 16/116 (14%) in Building D. Denominators are average daily census during the outbreak. Building A had significantly fewer culture-confirmed cases than the other buildings (P < .001). Fewer residents in Building A, 47% compared with 61% in Buildings B, C, and D, were participants in a formal study of influenza. Eight of 15 respiratory illnesses identified during the outbreak that were not cultured occurred in Building A. These factors could not account for the difference in attack rates. Building A has a unique ventilation system, more square feet of public space per resident, and does not contain office space that serves the entire four-building facility. Our retrospective observation suggests that architectural design may influence the attack rate of influenza A in nursing homes.
Research Interests:
Background/Aims When the randomized clusters in a cluster randomized trial are selected based on characteristics that influence treatment effectiveness, results from the trial may not be directly applicable to the target population. We... more
Background/Aims When the randomized clusters in a cluster randomized trial are selected based on characteristics that influence treatment effectiveness, results from the trial may not be directly applicable to the target population. We used data from two large nursing home–based pragmatic cluster randomized trials to compare nursing home and resident characteristics in randomized facilities to eligible non-randomized and ineligible facilities. Methods We linked data from the high-dose influenza vaccine trial and the Music & Memory Pragmatic TRIal for Nursing Home Residents with ALzheimer’s Disease (METRICaL) to nursing home assessments and Medicare fee-for-service claims. The target population for the high-dose trial comprised Medicare-certified nursing homes; the target population for the METRICaL trial comprised nursing homes in one of four US-based nursing home chains. We used standardized mean differences to compare facility and individual characteristics across the three groups and logistic regression to model the probability of nursing home trial participation. Results In the high-dose trial, 4476 (29%) of the 15,502 nursing homes in the target population were eligible for the trial, of which 818 (18%) were randomized. Of the 1,361,122 residents, 91,179 (6.7%) were residents of randomized facilities, 463,703 (34.0%) of eligible non-randomized facilities, and 806,205 (59.3%) of ineligible facilities. In the METRICaL trial, 160 (59%) of the 270 nursing homes in the target population were eligible for the trial, of which 80 (50%) were randomized. Of the 20,262 residents, 973 (34.4%) were residents of randomized facilities, 7431 (36.7%) of eligible non-randomized facilities, and 5858 (28.9%) of ineligible facilities. In the high-dose trial, randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (132.5 vs 145.9 and 91.9, respectively), for-profit status (91.8% vs 66.8% and 68.8%), belonging to a nursing home chain (85.8% vs 49.9% and 54.7%), and presence of a special care unit (19.8% vs 25.9% and 14.4%). In the METRICaL trial randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (103.7 vs 110.5 and 67.0), resource-poor status (4.6% vs 10.0% and 18.8%), and presence of a special care unit (26.3% vs 33.8% and 10.9%). In both trials, the characteristics of residents in randomized facilities were similar across the three groups. Conclusion In both trials, facility-level characteristics of randomized nursing homes differed considerably from those of eligible non-randomized and ineligible facilities, while there was little difference in resident-level characteristics across the three groups. Investigators should assess the characteristics of clusters that participate in cluster randomized trials, not just the individuals within the clusters, when examining the applicability of trial results beyond participating clusters.
Research Interests:
Research Interests: Health Sciences, Geriatrics, Evidence Based Medicine, Health Care, Evaluation, and 15 moreCommunicable Diseases, Activities of Daily Living, Biological Sciences, Disease Outbreaks, Humans, Infection, Care, Fever of Unknown Origin, Body Temperature, Aged, GuideLine, Clinical Infectious Diseases, Homes for the Aged, Frail elderly, and Cross Infection
Research Interests:
OBJECTIVE To determine if implementation of Project Re-Engineered Discharge (RED), designed for hospitals but adapted for skilled nursing facilities (SNFs), reduces hospital readmissions after SNF discharge to the community in residents... more
OBJECTIVE To determine if implementation of Project Re-Engineered Discharge (RED), designed for hospitals but adapted for skilled nursing facilities (SNFs), reduces hospital readmissions after SNF discharge to the community in residents admitted to the SNF following an index hospitalization. DESIGN A pragmatic trial. SETTING AND PARTICIPANTS SNFs in southeastern Massachusetts, and residents discharged to the community. METHODS We compared SNFs that deployed an adapted RED intervention to a matched control group from the same region. The primary outcome was hospital readmission within 30 days after SNF discharge, among residents who had been admitted to the SNF following an index hospitalization and then discharged home. January 2016 through March 2017 was the baseline period; April 2017 through June 2018 was the follow-up period (after implementation of the intervention). We used a difference-in-differences analysis to compare the intervention SNFs to the control group, using generalized estimating equation regression and controlling for facility characteristics. RESULTS After implementation of RED, readmission rates were lower across all 4 measures in the intervention group; control facilities' readmission rates remained stable or increased. The relative decrease was 0.9% for the primary outcome of hospital readmission within 30 days after SNF discharge and 1.7% for readmission within 30 days of the index hospitalization discharge date (P ≤ .001 for both comparisons). CONCLUSIONS AND IMPLICATIONS We found that a systematic discharge process developed for the hospital can be adapted to the SNF environment and can reduce readmissions back to the hospital, perhaps through improved self-management skills and better engagement with community services. This work is particularly timely because of Medicare's new Value-Based Purchasing Program, in which nursing homes can receive incentive payments if their hospital readmission rates are low relative to their peers. To verify its scalability and broad potential, RED should be validated across a broader diversity of SNFs nationally.
Research Interests:
Research Interests:
To describe the epidemiology of and clinical findings associated with a rhinovirus outbreak that occurred among institutionalized elderly persons. Retrospective review of medical records and nursing surveillance reports. A 685-bed,... more
To describe the epidemiology of and clinical findings associated with a rhinovirus outbreak that occurred among institutionalized elderly persons. Retrospective review of medical records and nursing surveillance reports. A 685-bed, long-term care facility for veterans and their spouses. 33 persons from whom rhinovirus was cultured. Throat and nasopharyngeal virus culture; review of medical records to determine underlying diseases, signs and symptoms of respiratory illness, illness duration, and interventions during illness; and review of nursing surveillance reports to determine room locations of ill persons. Between 14 August and 2 September 1993, the number of respiratory illnesses increased. Throat and nasopharyngeal virus cultures were taken from 67 ill residents; 33 cultures yielded rhinovirus, and no other respiratory virus was isolated. Geographic clustering of persons infected with rhinovirus was observed. Of those persons with rhinovirus infections, 100% had upper respiratory symptoms, 34% had gastrointestinal symptoms, 71% had systemic symptoms, 66% had lower respiratory symptoms (including productive cough), and 52% had new abnormalities on lung auscultation. The 17 persons with rhinovirus infection who had chronic obstructive pulmonary disease had more severe illnesses: Five (29%) required glucocorticoid or bronchodilator therapy for illness-associated bronchospasm; 2 required transfer out of the facility; 1 developed a radiographically documented infiltrate; and 1 died of respiratory failure. Rhinovirus may cause epidemic, clinically important respiratory illness in nursing homes residents. A large proportion of residents may become ill, and infection may be severe in persons with underlying lung disease.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
There is an increasing incidence of infectious complications caused by extraintestinal pathogenic Escherichia coli (ExPEC) after transrectal ultrasound-guided prostate needle biopsy (TRUS-PNB), and a need for prophylaxis methods effective... more
There is an increasing incidence of infectious complications caused by extraintestinal pathogenic Escherichia coli (ExPEC) after transrectal ultrasound-guided prostate needle biopsy (TRUS-PNB), and a need for prophylaxis methods effective against associated antibiotic-resistant organisms. We aimed to identify the O-serotypes of ExPEC isolates collected in a sample of 60 patients with invasive ExPEC disease (IED) after TRUS-PNB, by serotype-specific agglutination and polymerase chain reaction (PCR) assays. The prevalence of O-serotypes included in a tetravalent ExPEC vaccine was 38.3% by agglutination and 46.7% by PCR, while the prevalence of O-serotypes included in a decavalent vaccine was 58.3% and 73.3%, respectively. Therefore, compared to the tetravalent vaccine, the decavalent vaccine would theoretically provide coverage for serotypes carried by a higher proportion of circulating ExPEC in patients undergoing TRUS-PNB, including a high proportion of antibiotic-resistant organisms.
Research Interests:
Research Interests:
Research Interests:
OBJECTIVE To evaluate a bundled electronic intervention to improve antibiotic prescribing practices in US nursing homes. DESIGN Prospective mixed-methods quality improvement intervention. SETTING AND PARTICIPANTS Nursing staff and... more
OBJECTIVE To evaluate a bundled electronic intervention to improve antibiotic prescribing practices in US nursing homes. DESIGN Prospective mixed-methods quality improvement intervention. SETTING AND PARTICIPANTS Nursing staff and residents in 13 nursing homes, and residents in 8 matched-control facilities (n = 21 facilities total, from 2 corporations). METHODS This study involved a 2-month development period (n = 5 facilities) focused on the acceptability and feasibility of a bundled electronic intervention consisting of 3 tools, followed by a 15-month implementation period (n = 8 facilities) during which we used rapid-cycle quality improvement methods to refine and add to the bundle. We used mixed-methods data from providers, intervention tools, and health records to assess feasibility and conduct a difference-in-difference analysis among the 8 intervention sites and 8 pair-matched controls. RESULTS Nurses at 5 pilot sites reported that initial versions of the electronic tools were acceptable and feasible, but barriers emerged when 8 different facilities began implementing the tools, prompting iterative revisions to the training and bundle. The final bundle consisted of 3 electronic tools and training that standardized digital documentation to document and track a change in resident condition, infections, antibiotic prescribing, and antibiotic follow-up. By the end of the implementation phase, all 8 facilities were using at least 1 of the 3 tools. Early antibiotic discontinuation increased 10.5% among intervention sites but decreased 10.8% among control sites. CONCLUSIONS AND IMPLICATIONS The 3 tools in our bundled electronic intervention capture clinical and prescribing data necessary to assess changes in antibiotic use and were feasible for nurses to adopt. Achieving this required modifying the tools and training before the intervention reached its final form. Comparisons of rates of antibiotic use at intervention and control facilities showed promising improvement in antibiotic discontinuation, demonstrating that the intervention could be evaluated using secondary electronic health record data.
Research Interests:
Fourteen female monkeys (Macaca mulatta) received a trivalent influenza vaccine and antibody response was determined by a change in plasma antibody content (ELISA) before and after vaccine. Lymphocyte cultures were also established from... more
Fourteen female monkeys (Macaca mulatta) received a trivalent influenza vaccine and antibody response was determined by a change in plasma antibody content (ELISA) before and after vaccine. Lymphocyte cultures were also established from these monkeys and the level of antibody response did not correlate with mitogen-induced lymphocyte blastogenesis or natural killer cell function. In vitro anti-influenza antibody synthesis, however, was found to correlate well with the in vivo response. That is, monkeys who were non-responders, as determined by lack of change in plasma antibody content, were also non-responders in vitro. Accordingly, we believe that vaccine response is not necessarily a measure of immune competence but its measurement may, none the less, have clinical utility. The excellent correlation of in vivo and in vitro response provides predictive value for the in vitro test. Furthermore, because the correlation is good, the in vitro test may be useful as a tool in immunopharmacology and toxicology.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Background: Examining racial disparities in the treatment of heart failure (HF) patients and the effects of palliative care (PC) consultation is important to developing culturally competent clinical behaviors. Objective: To compare... more
Background: Examining racial disparities in the treatment of heart failure (HF) patients and the effects of palliative care (PC) consultation is important to developing culturally competent clinical behaviors. Objective: To compare burdensome transitions for Black and White Veterans hospitalized with HF after PC consultation. Participants: This retrospective study evaluated Veterans admitted for HF to Veterans Administration hospitals who received PC consultation from October 2010 through August 2017. Methods: We propensity-matched Black to White Veterans using demographic, comorbidity, clinical, hospital, and survival time data. Results: Propensity matching of our cohort (n = 5638) yielded 796 Black and White Veterans (total n = 1592) who were well-matched on observed variables (standard mean difference <0.15 for all variables). Matched Black Veterans had more burdensome transitions than White Veterans (n = 218, 27.4% vs. n = 174, 21.9%; p = 0.011) over the six-month follow-up period. Conclusions: This propensity-matched cohort found racial differences in burdensome transitions among admitted HF patients after PC consultation.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
We examined whether the second monovalent SARS-CoV-2 mRNA booster increased antibody levels and their neutralizing activity to Omicron variants in nursing home residents (NH) residents and healthcare workers (HCW). We sampled 367 NH... more
We examined whether the second monovalent SARS-CoV-2 mRNA booster increased antibody levels and their neutralizing activity to Omicron variants in nursing home residents (NH) residents and healthcare workers (HCW). We sampled 367 NH residents and 60 HCW after primary mRNA vaccination, first and second boosters, for antibody response and pseudovirus neutralization assay against SARS-CoV-2 wild-type (WT) (Wuhan-Hu-1) strain and Omicron BA1 variant. Antibody levels and neutralizing activity progressively increased with each booster but subsequently waned over weeks. NH residents, both those without and with prior infection, had a robust geometric mean fold rise (GMFR) of 10.2 (95% CI 5.1, 20.3) and 6.5 (95% CI 4.5, 9.3) respectively in Omicron-BA.1 subvariant specific neutralizing antibody levels following the second booster vaccination (p<0.001). These results support the ongoing efforts to ensure that both NH residents and HCW are up to date on recommended SARS-CoV-2 vaccine boost...