Nursing Home Physicians Research Articles

Physicians’ understandings and experience of advance care planning in Norwegian nursing homes: a qualitative study

BackgroundAdvance care planning is a way of facilitating conversations with patients about future health care, values, and preferences at end of life. Nursing home physicians have the medical responsibility and the main obligation to facilitate planned meetings with patients. Although there has been a great deal of focus on establishing advance care planning in Norwegian nursing homes, it has yet to be widely implemented. Stated reasons are that the work routines in a nursing home do not include such meetings or that implementation seems complex due to frail patients. The aim of this study is thus to explore how physicians understand and experience advance care planning and follow-up of care plans in Norwegian nursing homes.MethodsThe study has a qualitative research design with a phenomenological-hermeneutic approach based on interviews of twelve nursing home physicians working in community care. Interviews were conducted in February 2023 to May 2023, using a semi-structured interview guide. All interviews were recorded on audio files, transcribed, and analyzed using structural text analysis.ResultsThe findings are presented based on the following themes: (1) advance care planning is a dialog and a process, (2) advance care planning implies clarifying mutual expectations, and (3) advance care planning that brings relief and hope to patients is a medical art.ConclusionsAdvance care planning is a complex and dynamic process that implies medical treatment, decisions on treatment level, pain relief, and formulation of care plans where the patient’s self-determination and personal values are respected. It implies an ongoing dialogue between physicians, patients, and their relatives about values such as dignity, self-understanding, social relations, and existential questions at end of life. Advance care planning requires a holistic approach that meets patients’ psychological and existential needs such as comfort, trust, hope, and respect as well as their preferences and concerns.

Emergency physicians' and nurses' perception on the adequacy of emergency calls for nursing home residents: a non-interventional prospective study.

A considerable percentage of daily emergency calls are for nursing home residents. With the ageing of the overall European population, an increase in emergency calls and interventions in nursing homes (NH) is to be expected. A proportion of these interventions and hospital transfers may be preventable and could be considered as inappropriate by prehospital emergency medical personnel. The study aimed to understand Belgian emergency physicians' and emergency nurses' perspectives on emergency calls and interventions in NHs and investigate factors contributing to their perception of inappropriateness. An exploratory non-interventional prospective study was conducted in Belgium among emergency physicians and emergency nurses, currently working in prehospital emergency medicine. Electronic questionnaires were sent out in September, October and November 2023. Descriptive statistics were used to analyze the overall results, as well as to compare the answers between emergency physicians and emergency nurses about certain topics. A total of 114 emergency physicians and 78 nurses responded to the survey. The mean age was 38 years with a mean working experience of 10 years in prehospital healthcare. Nursing home staff were perceived as understaffed and lacking in competence, with an impact on patient care especially during nights and weekends. General practitioners were perceived as insufficiently involved in the patient's care, as well as often unavailable in times of need, leading to activation of Emergency Medical Services (EMS) and transfers of nursing home residents to the Emergency Department (ED). Advance directives were almost never available at EMS interventions and transfers were often not in accordance with the patient's wishes. Palliative care and pain treatment were perceived as insufficient. Emergency physicians and nurses felt mostly disappointed and frustrated. Additionally, differences in perception were noted between emergency physicians and nurses regarding certain topics. Emergency nurses were more convinced that the nursing home physician should be available 24/7 and that transfers could be avoided if nursing home staff had more authority regarding medical interventions. Emergency nurses were also more under the impression that pain management was inadequate, and emergency physicians were more afraid of the medical implications of doing too little during interventions than emergency nurses. Suggestions to reduce the number of EMS interventions were more general practitioner involvement (82%), better nursing home staff education/competences (77%), more nursing home staff (67%), mobile palliative care support teams (65%) and mobile geriatric nursing intervention teams (52%). EMS interventions in nursing homes were almost never seen as necessary or indicated by emergency physicians and nurses, with the appropriate EMS level almost never being activated. The following key issues were found: shortages in numbers and competence of nursing home staff, insufficient primary care due to the unavailability of the general practitioner as well as a lack of involvement in patient care, and an absence of readily available advance directives. General practitioners should be more involved in the decision to call the Emergency Medical Services (EMS) and to transfer nursing home residents to the Emergency Department. Healthcare workers should strive for vigilance regarding the patients' wishes. The emotional burden of deciding on an avoidable hospital admission of nursing home residents, perhaps out of fear for medico-legal consequences if doing too little, leaves the emergency physicians and nurses frustrated and disappointed. Improvements in nursing home staffing, more acute and chronic general practitioner consultations, and mobile geriatric and palliative care support teams are potential solutions. Further research should focus on the structural improvement of the above-mentioned shortcomings.

Unlocking Deprescribing Potential in Nursing Homes: Insights from a Focus Group Study with Healthcare Professionals.

The nursing home population is characterized by multimorbidity and disabilities, which often result in extensive prescription of medication and subsequent polypharmacy. Deprescribing, a planned and supervised process of dose reduction or total cessation of medication, is a solution to combat this. This study aimed to identify barriers and enablers of deprescribing as experienced by nursing home physicians (NHPs) and collaborating pharmacists in the specific nursing home setting. This qualitative study utilized a semi-structured interview format with two focus groups consisting of a mix of NHPs and pharmacists.Directed content analysis was performed based on the Theoretical Domains Framework, a validated framework for understanding determinants of behavior change among health care professionals. Sixteen health care professionals participated in two focus groups, including 13 NHPs and three pharmacists. The participating NHPs and pharmacists believed that deprescribing is a valuable process with enablers, such as multidisciplinary collaboration, good communication with patients and family, and involvement of the nursing staff. NHPs and pharmacists view deprescribing as a core task and feel assured in their ability to carry it out successfully. However, they also noted barriers: deprescribing is time-consuming; communication with residents, their relatives or medical specialists is difficult; and electronic patient systems often do not adequately support it. This study provides insight into the various barriers and enablers faced by NHPs and pharmacists when deprescribing in nursing homes. Specific for this population, deprescribing barriers focus on communication (with residents and their relatives, and also with medical specialists) and resources, while knowledge and expertise are mentioned as enablers.

Validity of stroke severity assessment using medical records in a population-based cohort

ObjectivesStroke severity is an important prognostic indicator of morbidity and mortality, but often not recorded outside of specialised stroke centres. We aimed to develop a scoring rule and validate standardised assessment of the National Institutes of Health Stroke Scale (NIHSS) from medical records. MethodsWe developed a standardised assessment of the NIHSS from medical records. Four trained raters independently assessed the charts of 100 patients with first-ever stroke, randomly selected from the population-based Rotterdam Study cohort. Interrater agreement was determined using the intraclass correlation coefficient (ICC), and Fleiss’ kappa for major versus minor stroke. We validated the scoring method against 29 prospective, clinical NIHSS ratings, using Kendall's tau and Cohen's kappa. ResultsOf 100 included patients with stroke (mean age 80 years, 62% women), 71 (71%) were admitted to hospital and 9 (9%) were seen in outpatient clinic, whereas 20 (20%) were treated exclusively by their general practitioner or nursing home physician. Interrater agreement for retrospective, chart-based NIHSS ratings was excellent when assessed continuously (ICC: 0.90), and for minor versus major stroke (for NIHSS>3: κ=0.79, NIHSS>5: κ=0.78). Interrater agreement was good both for hospital-based and out-of-hospital settings (ICC: 0.97 and 0.75 respectively). Overall, assessment from medical records was in excellent agreement with prospective NIHSS ratings (τ=0.83; NIHSS>3: κ=0.93, and NIHSS>5: κ=0.93). However, for severe stroke (NIHSS>10) retrospective assessment tended to underestimate severity by 1-3 points on the NIHSS, which was accompanied by a somewhat lower interrater agreement for those more severe cases (NIHSS>10: κ=0.62). ConclusionsAssessment of stroke severity according to the NIHSS on the basis of medical records is feasible and reliable in population-based cohorts of patients with stroke. These findings facilitate more individualised risk estimates in observational studies that lack prospective ascertainment of stroke severity.

Setting up a Governance Framework for Secondary Use of Routine Health Data in Nursing Homes: Development Study Using Qualitative Interviews

In the nursing home sector, reusing routinely recorded data from electronic health records (EHRs) for knowledge development and quality improvement is still in its infancy. Trust in appropriate and responsible reuse is crucial for patients and nursing homes deciding whether to share EHR data for these purposes. A data governance framework determines who may access the data, under what conditions, and for what purposes. This can help obtain that trust. Although increasing attention is being paid to data governance in the health care sector, little guidance is available on development and implementation of a data governance framework in practice. This study aims to describe the development process of a governance framework for the "Registry Learning from Data in Nursing Homes," a national registry for EHR data on care delivered by nursing home physicians (in Dutch: specialist ouderengeneeskunde) in Dutch nursing homes-to allow data reusage for research and quality improvement of care. Relevant stakeholders representing practices, policies, and research in the nursing home sector were identified. Semistructured interviews were conducted with 20 people from 14 stakeholder organizations. The main aim of the interviews was to explore stakeholders' perspectives regarding the Registry's aim, data access criteria, and governing bodies' tasks and composition. Interview topics and analyses were guided by 8 principles regarding governance for reusing health data, as described in the literature. Interview results, together with legal advice and consensus discussions by the Registry's consortium partners, were used to shape the rules, regulations, and governing bodies of the governance framework. Stakeholders valued the involvement of nursing home residents and their representatives, nursing home physicians, nursing homes' boards of directors, and scientists and saw this as a prerequisite for a trustworthy data governance framework. For the Registry, involvement of these groups can be achieved through a procedure in which residents can provide their consent or objection to the reuse of the data, transparency about the decisions made, and providing them a position in a governing body. In addition, a data request approval procedure based on predefined assessment criteria indicates that data reuse by third parties aligns with the aims of the Registry, benefits the nursing home sector, and protects the privacy of data subjects. The stakeholders' views, expertise, and knowledge of other frameworks and relevant legislation serve to inform the application of governance principles to the contexts of both the nursing home sector and the Netherlands. Many different stakeholders were involved in the development of the Registry Learning from Data in Nursing Homes' governance framework and will continue to be involved. Engagement of the full range of stakeholders in an early stage of governance framework development is important to generate trust in appropriate and responsible data reuse.

Defining the Role and Value of Physicians Who Primarily Practice in Nursing Homes: Perspectives of Nursing Home Physicians.

To identify the perceptions of physicians with expertise in nursing home care on the value of physicians who primarily practice in nursing homes, often referred to as "SNFists," with the goal of enriching our understanding of specialization in nursing home care. Qualitative analysis of semistructured interviews. Virtual interviews conducted January 18-29, 2021. Participants included 35 physicians across the United States, who currently or previously served as medical directors or attending physicians in nursing homes. Interviews were conducted virtually on Zoom and professionally transcribed. Outcomes were themes resulting from thematic analysis. Participants had a mean 19.5 (SD= 11.3) years of experience working in nursing homes; 17 (48.6%) were female; the most common medical specializations were geriatrics (18; 51.4%), family medicine (8; 22.9%), internal medicine (7; 20.0%), physiatry (1; 2.9%), and pulmonology (1; 2.9%). Ten (28.6%) participants were SNFists. We identified 6 themes emphasized by participants: (1) An unclear definition and loose qualifications for SNFists may affect the quality of care; (2) Specific competencies are needed to be a "good SNFist"; (3) SNFists are distinguished by their unique practice approach and often provide services that are unbillable or underreimbursed; (4) SNFists achieve better outcomes, but opinions varied on performance measures; (5) SNFists may contribute to discontinuity of care; (6) SNFists remained in nursing homes during the COVID-19 pandemic. There is a strong consensus among physicians with expertise in nursing home care that SNFists provide higher quality care for residents than other physicians. However, a uniform definition of a SNFist based on competencies in addition to standardized performance measures are needed. Unbillable and underreimbursed services create disincentives to physicians becoming SNFists. Policy makers may consider modifying Medicare reimbursements to incentivize more physicians to specialize in nursing home care.

Barriers and facilitators of appropriate antibiotic use in primary care institutions after an antibiotic quality improvement program – a nested qualitative study

BackgroundAntibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs.MethodsAfter implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke.ResultsWe identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents’ next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound.ConclusionsOur qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians.

Clinical factors associated with recent medical care visits in nursing homes: a multi-site cross-sectional study

ObjectivesWe examined which resident-level clinical factors influence the provision of a recent medical care visit in nursing homes (NHs).DesignMulti-site cross-sectional.Setting and participantsWe extracted data on 3,556 NH residents from 18 NH facilities in Ontario, Canada, who received at minimum, an admission and first-quarterly assessment with the Resident Assessment Instrument Minimum Data Set (MDS) 2.0 between November 1, 2009, and October 31, 2017.MethodsWe conducted a secondary analysis of routinely collected MDS 2.0 data. The provision of a recent medical care visit by a physician (or authorized clinician) was assessed in the 14-day period preceding a resident’s first-quarterly MDS 2.0 assessment. We utilized best-subset multivariable logistic regression to model the adjusted associations between resident-level clinical factors and a recent medical care visit.ResultsTwo thousand eight hundred fifty nine (80.4%) NH residents had one or more medical care visits prior to their first-quarterly MDS 2.0 assessment. Six clinically relevant factors were identified to be associated with recent medical care visits in the final model: exhibiting wandering behaviours (OR = 1.34, 95% CI 1.09 – 1.63), presence of a pressure ulcer (OR = 1.37, 95% CI 1.05 – 1.78), a urinary tract infection (UTI) (OR = 1.52, 95% CI 1.06 – 2.18), end-stage disease (OR = 9.70, 95% CI 1.32 – 71.02), new medication use (OR = 1.31, 95% CI 1.09 – 1.57), and analgesic use (OR = 1.24, 95% CI 1.03 – 1.49).Conclusions and implicationsOur findings suggest that resident-level clinical factors drive the provision of medical care visits following NH admission. Clinical factors associated with medical care visits align with the minimum competencies expected of physicians in NH practice, including managing safety risks, infections, medications, and death. Ensuring that NH physicians have opportunities to acquire and strengthen these competencies may be transformative to meet the ongoing needs of NH residents.

Perceived quality of collaboration in dehydration care among Dutch nursing home professionals: A cross-sectional study.

AimTo explore the perceived quality of collaboration in dehydration care among nursing and medical staff in Dutch nursing homes.DesignA cross‐sectional study.MethodsAn online questionnaire was administered to nursing and medical staff in February 2020 to assess the quality of collaboration in dehydration care and its influencing factors. Descriptive statistics, chi‐square tests and multinomial logistic regression analysis were used to describe the results and examine differences between groups.ResultsIn total, 695 questionnaires were completed by multiple levels of (specialized) nursing staff and nursing home physicians. The quality of collaboration was assessed as good (23.2%), sufficient (59.4%) and insufficient (17.4%). Predicting factors related to perceiving the quality of collaboration as good were working experience, dehydration training during education and the presence of a dehydration protocol/guideline in the nursing home. Enabling factors related to collaboration in dehydration care were ‘availability of sufficient aids to detect dehydration’, ‘continuity in the care relationship’ and ‘sufficient background data of the resident in the care record’. Factors that hinder collaboration were ‘insufficient knowledge about dehydration among nursing and medical staff’, ‘the absence of a team meeting in which the topic dehydration is discussed’ and ‘insufficient staffing level among nursing and medical staff’.ConclusionCollaboration in dehydration care was generally assessed as sufficient. Participants with >10 years of working experience, who received dehydration training during their education and had a dehydration protocol/guideline available in the nursing home, perceived the quality of collaboration more often as good. Experienced barriers and enablers for collaboration in dehydration care varied between professional groups. Therefore, it is important to gain more insight into (informal) caregivers’ perceptions on what is expected from each other about dehydration care.ImpactCare professionals experience several limiting factors in collaborating in dehydration care. Addressing these factors could optimize dehydration care in Dutch nursing homes.

You can tell it works - Experiences from using the VIPS practice model in primary healthcare.

Person-centred care is a philosophy rather than a method ready for implementation and utilization in daily clinical work. Internationally, few methods for person-centred care have been widely adopted in clinical dementia care practice. In Norway, the VIPS practice model is one that is commonly used for the implementation and use of person-centred care in primary healthcare. Nursing home physicians, managers and leaders in the municipalities, care institutions and domestic nursing care services were eligible for inclusion if their workplace had implemented and used the VIPS practice model for a minimum of 12months. Individual interviews were conducted via Facetime, Skype or telephone and analysed with qualitative content analysis. In all, 20 respondents were included: one manager of health and care services in the municipality, six managers and leaders working in domestic care or daytime activity centres and 10 managers/leaders and three physicians working in nursing homes. Two global categories emerged: category 1: Change in staff's professional reasoning with two sub-categories: (a) an enhanced professional level in discussions and (b) a change in focus from task to person; and category 2: Changes in the clinical work, with three sub-categories: (a) effective interventions, (b) a person-centred work environment and (c) changes in cooperation between stakeholders. Regular use of the VIPS practice model appeared to change the work culture for the benefit of both service users and frontline staff. Increased cooperation between frontline staff, nurses, physicians and next of kin was described. Staff were more focused on the needs of the service users, which resulted in care interventions tailored to the needs of the individual with dementia, loyalty to care plans and fewer complaints from next of kin.

Deprescribing Statins and Proton Pump Inhibitors in Nursing Home Residents; a Pragmatic Exploratory Study.

IntroductionPolypharmacy is common in the frail nursing home population and associated with an increased risk of adverse events, unplanned hospitalizations, and increased all-cause mortality. Deprescribing using a deprescribing algorithm might reduce unnecessary polypharmacy. This exploratory study was performed to determine the effect of this implicit deprescribing algorithm in deprescribing statins and proton pump inhibitors (PPIs) in nursing home residents.MethodMulticenter, longitudinal, single-arm exploratory study. All participants received the same deprescribing intervention to identify and deprescribe potentially inappropriate statins and/or PPIs. Residents across 10 nursing homes in the Netherlands were included if they used a statin and/or PPI. Residents in hospices or short-stay wards were excluded. The intervention involved a deprescribing algorithm in which nursing home physicians identified and, if possible, deprescribed potentially inappropriate statins and/or PPIs.ResultsSixty-seven residents participated in the study. At 3 months, deprescribing was successful in 52% of the residents. Six months after the intervention, all these residents still had their medication sustainably deprescribed.ConclusionBased on this study, deprescribing statins and PPIs using an implicit deprescribing algorithm is possible in a considerable number of nursing home residents.

Results of High-Protein, High-Calorie Oral Nutritional Supplementation in Malnourished Older People in Nursing Homes: An Observational, Multicenter, Prospective, Pragmatic Study (PROT-e-GER)

ObjectivesTo assess if the impact of oral nutritional supplements (ONS) on nutritional and functional status in malnourished older persons living in nursing homes shown by clinical trials are also found outside a trial setting. DesignObservational, multicenter, prospective, pragmatic study. Setting and ParticipantsThis study was carried out in 38 nursing homes throughout Spain. Nursing home physicians recruited consecutive residents, older than 65 years, with a diagnosis of malnutrition, when a clinical decision to start ONS had been taken after unsuccessful initial management with dietary interventions. InterventionThe participants received daily 2 bottles of an energy-rich, high-protein commercial ONS for 3 months. MeasuresPrimary outcomes were changes in nutritional status [body weight, body mass index (BMI), and Mini Nutritional Assessment-Short Form (MNA-SF)]; secondary outcomes were functional changes [Functional Ambulation Classification, Barthel index, handgrip strength, and Short Physical Performance Battery (SPPB)], as well as safety and adherence after 12 weeks of follow-up. ResultsA total of 282 residents (median age 86 years, 67% women) were included, and 244 (86.5%) completed the follow-up. At baseline, 77.3% of the participants were malnourished (BMI 19.7 kg/m2, interquartile range 18.3–21.8). After 12 weeks of follow-up, participants experienced significant increases in body weight (2.6 ± 3.1 kg, 5.2 ± 5.9%), BMI (1.0 ± 1.2 kg/m2) and MNA-SF (4.0 ± 2.5 points). There were also significant improvements in functional status measured by the Barthel index, handgrip strength, SPPB, and gait speed. Good adherence was registered in 94.6% of the participants. No relevant side effects were found. Conclusions and ImplicationsImprovements in nutritional and functional status can be found when using a high-protein, high-calorie ONS in older undernourished people living in nursing homes.

Improving antibiotic initiation and duration prescribing among nursing home physicians using an audit and feedback intervention: a theory-informed qualitative analysis

BackgroundIn nursing homes, 25%–75% of antibiotic days of treatment are inappropriate or unnecessary and are often continued for longer durations than necessary. In Ontario, physicians can receive a provincial audit...

Clinical features and medical care factors associated with mortality in French nursing homes during the COVID-19 outbreak

ObjectivesThis study aimed to identify demographic, clinical and medical care factors associated with mortality in three nursing homes in France. MethodsTwo nursing homes were hospital-dependent, had connections with infection prevention and control departments, and had permanent physicians. A third nursing home had no direct connection with a general hospital, no infection control practitioner, and no permanent physician. The main outcome was death. ResultsDuring the first 3 months of the outbreak, 224 of 375 (59.7%) residents were classified as COVID-19 cases and 57 of 375 (15.2%) died. The hospital-dependent nursing homes had lower COVID-19 case fatality rates in comparison with the non-hospital-dependent nursing home (15 [6.6%] vs 38 [25.8%], OR 0.20 [0.11–0.38], p = 0.001). During the first 3 weeks of the outbreak, mortality in COVID-19 patients decreased if they had a daily clinical examination (OR: 0.09 [0.03–0.35], p = 0.01), three vital signs measurement per day (OR: 0.06 [0.01–0.30], p = 0.001) and prophylactic anticoagulation (OR: 0 [0.00–0.24], p = 0.001). ConclusionsThis study suggested that high mortality rates in some nursing homes during the COVID-19 outbreak might have been contributed by a lack of medical care management. Increasing human and material resources, encouraging presence of nursing home physicians and establishing a connection with general hospitals should be considered to deal with present and future health disasters in nursing homes.

A prospective evaluation of the Flacker-Kiely One Year Mortality Score and the added value of NT-proBNP

Objective: Several mortality indices have been constructed to aid clinical decision making in older adults. We aimed to prospectively validate the Flacker-Kiely (FK) mortality index in a Norwegian nursing home cohort, which has not been done before, and explore whether NT-ProBNP could improve its discriminatory power.Methods: We performed a cohort/mortality study. From November 2017 to July 2018, physicians in all public long-term nursing homes in Bergen, Norway, scored residents according to the original Flacker Kiely index. Mortality data were derived from the Norwegian Cause of Death Registry and NT-ProBNP values were obtained from routinely collected blood chemistry. An alternative FK index using the NT-ProBNP-value as a marker for the presence of heart failure was constructed (FK NT-ProBNP index). The ProBNP cut-off value was selected based on a Cox regression model (“dead/alive 1 year”/” NT-ProBNP (Ng/l)”, where the value with the highest Youden index was identified. We judged index performance by using c-statistics.Results: Both the original FK index and the constructed FK NT-ProBNP index discriminated between risk strata. The FK NT-ProBNP index yielded a C-index of 0.66 compared to 0.62 for the original FK index. Optimal discriminatory power was shown with a NT-ProBNP cut-off value of 1,595 Ng/l as heart failure criterion, and FK NT-ProBNP score 6.6.Conclusions: The prospective mortality estimation ability of the FK-index was comparable to previous retrospective studies. The inclusion of NT-ProBNP as a heart failure criterion strengthen the discriminatory power and utility of the index, both in clinic and administration.

"Medication Is Just One Piece of the Whole Puzzle": How Nursing Homes Change Their Use of Antipsychotic Medications.

Antipsychotic medication use for nursing home residents with dementia poses major patient safety challenges. This article investigates health professionals' experiences with decision-making during changes under the National Partnership to Improve Dementia Care in Nursing Homes (National Partnership) and its companion state coalitions. These programs were introduced in 2012 to encourage reductions in antipsychotic use and increased use of nonpharmacological treatments for dementia. Interviews with 40 nursing home physicians and staff in seven states found that reducing antipsychotics is more time and resource-intensive than relying on medication, because it requires a person-centered approach. However, respondents supported reductions in antipsychotic use, and indicated that with sufficient staffing, effective communications, and training, they could create or implement individualized treatments. Their positive attitudes suggest that the National Partnership has been a catalyst in reducing antipsychotic medications, and their perspectives can inform further research, policy and practice in nursing homes toward achieving quality dementia care.

Physicians' perspectives on estimating and communicating prognosis in palliative care: a cross-sectional survey.

BackgroundAdvance care planning (ACP) can help to enhance the care of patients with limited life expectancy. Despite physicians’ key role in ACP, the ways in which physicians estimate and communicate prognosis can be improved.AimTo determine how physicians in different care settings self-assess their performance in estimating and communicating prognosis to patients in palliative care, and how they perceive their communication with other physicians about patients’ poor prognosis.Design & settingA survey study was performed among a random sample of GPs, hospital physicians (HPs), and nursing home physicians (NHPs) in the southwest of the Netherlands (n = 2212).MethodA questionnaire was developed that had three versions for GPs, HPs, and NHPs. Each specialism filled in an appropriate version.ResultsA total of 547 physicians participated: 259 GPs, 205 HPs, and 83 NHPs. In the study, 61.1% of physicians indicated being able to adequately estimate whether a patient will die within 1 year, which was associated with use of the Surprise Question (odds ratio [OR] = 1.65, P = 0.042). In the case of a prognosis of <1 year, 75.0% of physicians indicated that they communicate with patients about preferences regarding treatment and care, which was associated with physicians being trained in palliative care (OR = 2.02, P=0.007). In cases where patients with poor prognosis are discharged after hospital admission, 83.4% of HPs indicated that they inform GPs about these patients’ preferences compared with 29.0% of GPs, and 21.7% of NHPs, who indicated that they are usually adequately informed about the preferences.ConclusionThe majority of physicians indicated that they believe they can adequately estimate patients’ limited life expectancy and that they discuss patients’ preferences for care. However, more physicians should be trained in communicating about patients’ poor prognosis and care preferences.

Physicians' and Public Attitudes Toward Euthanasia in People with Advanced Dementia.

BACKGROUND/OBJECTIVESTo explore the opinion of the Dutch general public and of physicians regarding euthanasia in patients with advanced dementia.DESIGNA cross‐sectional survey.SETTINGThe Netherlands.PARTICIPANTSRandom samples of 1,965 citizens (response = 1,965/2,641 [75%]) and 1,147 physicians (response = 1,147/2,232 [51%]).MEASUREMENTSThe general public was asked to what extent they agreed with the statement “I think that people with dementia should be eligible for euthanasia, even if they no longer understand what is happening (if they have previously asked for it).” Physicians were asked whether they were of the opinion that performing euthanasia is conceivable in patients with advanced dementia, on the basis of a written advance directive, in the absence of severe comorbidities. Multivariable logistic regression was performed to identify factors associated with the acceptance of euthanasia.RESULTSA total of 60% of the general public agreed that people with advanced dementia should be eligible for euthanasia. Factors associated with a positive attitude toward euthanasia were being female, age between 40 and 69 years, and higher educational level. Considering religion important was associated with lower acceptance. The percentage of physicians who considered it acceptable to perform euthanasia in people with advanced dementia was 24% for general practitioners, 23% for clinical specialists, and 8% for nursing home physicians. Having ever performed euthanasia before was positively associated with physicians considering euthanasia conceivable. Being female, having religious beliefs, and being a nursing home physician were negatively associated with regarding performing euthanasia as conceivable.CONCLUSIONThere is a discrepancy between public acceptance of euthanasia in patients with advanced dementia and physicians' conceivability of performing euthanasia in these patients. This discrepancy may cause tensions in daily practice because patients' and families' expectations may not be met. It urges patients, families, and physicians to discuss mutual expectations in these complex situations in a comprehensive and timely manner. J Am Geriatr Soc 68:2319–2328, 2020.

Less Is More: The Impact of Deprescribing Psychotropic Drugs on Behavioral and Psychological Symptoms and Daily Functioning in Nursing Home Patients. Results From the Cluster-Randomized Controlled COSMOS Trial

ObjectiveTo investigate the impact of medication reviews using collegial mentoring and systematic clinical evaluation on psychotropic prescriptions, behavioral and psychological symptoms of dementia (BPSD), and activities of daily living (ADL). DesignFour-month multicenter, multicomponent, cluster-randomized, single-blinded controlled trial. SettingThirty-three Norwegian nursing homes including 67 nursing home wards (clusters). ParticipantsA total of 723 enrolled patients, of which 428 participated in the study; 217 were randomized to the intervention and 211 to care as usual (control). InterventionThe COSMOS intervention consisted of Communication, Systematic pain management, Medication reviews, Organization of activities, and Safety. During medication review, the nursing home physician evaluated treatment with colleagues systematically using the results from validated clinical assessments. MeasurementsMean changes from baseline to month 4 in the number of prescribed psychotropic drugs (antipsychotics, anxiolytics, hypnotics or sedatives, antidepressants, and antidementia drugs); Neuropsychiatric Inventory Nursing Home Version (NPI-NH) and Cornell Scale of Depression in Dementia (CSDD); Lawton and Brody's Physical Self Maintenance Scale (PSMS). ResultsCompared to control, the mean change in prescribed psychotropic drugs was reduced both in total and regular number, while mean changes in NPI-NH and CSDD scores did not differ between the groups. Mean change in PSMS showed improvement in the intervention group, and deterioration in the control group. ConclusionMedication reviews using collegial mentoring and systematic clinical evaluation led to safe deprescribing, as the reductions in psychotropic drug use did not negatively affect BPSD, while ADL improved.

Optimisation of Heart Failure Management in Nursing Homes Using Point-of-Care Ultrasonography: Harmonious Trial Rationale and Design.

IntroductionHeart failure is common in the nursing home population and presents many diagnostic and therapeutic challenges. Point-of-care ultrasonography is a bedside method that can be used to assess volume status more reliably than clinical examination. This trial was conceived to test whether point-of-care ultrasonography-guided management improves heart failure outcomes among nursing home residents.MethodsNursing home residents with heart failure will be enrolled in a multi-centre, prospective, randomised controlled trial. Residents will first be screened for heart failure. Patients with heart failure will be randomised in 1:1 fashion into two groups. Nursing home physicians will adjust diuretic therapy according to volume status for six months. Point-of-care ultrasonography will be used in the test group and clinical examination in the control group. The primary endpoint will be heart failure deterioration, defined as a composite of any of the following four events: the need for an intravenous diuretic application, the need for an emergency service intervention, the need for unplanned hospitalisation for non-injury causes, or death from whatever cause.Expected resultsThe expected prevalence of heart failure among nursing home residents is above 10%. Point-of-care ultrasonography-guided heart failure management will reduce the number of deteriorations of heart failure in the nursing home population.ConclusionThis study will explore the usefulness of point-of-care ultrasonography for heart failure management in the nursing home population.