Nursing Home Physicians Research Articles

PC-FACS

PC-FACS

The difficulty of predicting mortality in nursing home residents

Prognostic tools or risk scores that accurately estimate mortality risk could provide valuable information for elderly nursing home residents, their families, and physicians when establishing goals of care, such as when considering a shift to palliative care. Several Dutch and US studies found male gender, ADL impairment, age, poor intake, and shortness of breath were consistently associated with higher mortality risk both in dementia patients and mixed nursing home populations. Nevertheless, existing prognostic models exhibit only fair performance in identifying those at high risk of dying, which likely impedes their use. Accurately predicting death is challenging for conceptual and practical reasons. It is clearly time for a new research agenda. Future model development might focus on specific conditions (e.g., pneumonia), alternative treatments, outcomes other than mortality, and identifying the best approach to selecting risk cut-off scores to support palliative care decisions. Further study of risk scores might include using them in developing stepwise care planning processes, combining them with physicians’ own estimates, and using them as educational tools. Developing a balanced view of the mortality-risk score's usefulness in nursing homes will require further validating prognostic models and testing clinical impact in a variety of settings.

Polypharmazie ist ein Indikator für kurze Überlebensdauer im Pflegeheim - Daran ändert das Absetzen von Medikamenten nichts

To examine the influence of polypharmacy ordered by the pretreating site and deprescribing (i.e. the appropriate withdrawal of prescribed drugs) by the nursing home physician on survival time. Retrospective Analysis of medical databasis from 1,249 patients, thereof 611 in a nursing home with practice of deprescribing. 70% of the patients with excessive polypharmacy (>9 drugs), 57% of those with polypharmacy (6 to 9 drugs) and 43% of the remaining patients (<6 drugs) deceased within 286 days after admission (chi-squared 2 DF = 43.72; p <0.001). Deprescribing by the nursing home physician at admission revealed no influence on survival time. Polypharmacy is not the reason, but an indicator for a poor prognosis, which is not altered by deprescribing.

Staff and family relationships in end-of-life nursing home care

This article examines the involvement of residents and their relatives in end-of-life decisions and care in Norwegian nursing homes. It also explores challenges in these staff-family relationships. The article is based on a nationwide survey examining Norwegian nursing homes' end-of-life care at ward level. Only a minority of the participant Norwegian nursing home wards 'usually' explore residents' preferences for care and treatment at the end of their life, and few have written procedures on the involvement of family caregivers when their relative is in the terminal phase. According to the respondents, most staff seem to comfort relatives well. However, several challenges were described. The study revealed a need for better procedures in the involvement of residents and relatives in nursing home end-of-life care. The findings emphasize a need to strengthen both the involvement of nursing home physicians and staff communication skills.

Reasons to Prescribe Antipsychotics for the Behavioral Symptoms of Dementia: A Survey in Dutch Nursing Homes Among Physicians, Nurses, and Family Caregivers

Despite serious safety concerns, prescription rates of antipsychotics for the treatment of the behavioral and psychological symptoms of dementia remain high, especially in nursing homes. This high prevalence of antipsychotic use cannot be explained by the modest success rate reported in the literature. In this study, we aim at clarifying the reasons for prescribing an antipsychotic drug in behavioral and psychological symptoms of dementia and look at the role of nurses and family caregivers in the decision-making process that precedes the prescription of an antipsychotic drug. Questionnaire used in a one-on-one interview with elderly care physicians, nurses, and family caregivers. We conducted a survey in 23 nursing homes in the Netherlands. On each dementia ward, the physician selected 1 or 2 patients who started antipsychotics most recently. An interviewer then held a structured questionnaire with the physician, the nurse, and the first relative of the patient. The first part of the interview consisted of questions about the general ideas of the physicians and the second part consisted of case-related questions to physicians, nurses, and family caregivers. Physicians, nurses, and family caregivers generally consider the possible benefits of antipsychotics to outweigh the risk of side effects. The main reasons to start therapy are agitation and aggression. Physicians felt pressured by nurses to prescribe in 17% of cases. Physicians felt supported by the guideline of the Dutch Association of Elderly Care Physicians. The estimated average success rate in the discussed cases (the patient is expected to improve on the target behavior) among physicians was 50%, nurses reported 53%, and relatives 55%. The most frequently expected adverse reactions were increased fall risk, sedation, and parkinsonism. Nurses expected cognitive decline. The family felt insufficiently informed about the side effects in 44% of the cases. The interviewed nursing home physicians and nurses expect almost half of their patients with dementia and behavioral disturbances to benefit from antipsychotic therapy. Serious side effects were expected to occur only sporadically. These expectations may contribute to the high rate of antipsychotic use among these patients.

Strategies to improve care transitions between nursing homes and emergency departments.

To identify testable solutions that may improve the quality and safety of care transitions between nursing homes (NHs) and emergency departments (EDs). Structured focus group interviews. Group interviews took place in Indianapolis, Indiana. NH administrators, nurses, and physicians; emergency medical services directors, paramedics, and emergency medicine technicians; ED nurses and physicians; and a representative from the Indiana State Department of Health. Opinions, perceptions, and insights of participants. Eighteen participants were included. The central theme was the need for additional structure to support care transitions between NHs and EDs. Participants agreed that the structure afforded by hospital-to-hospital transfers would benefit patients and providers during transitions between NHs and EDs. Because transfer forms currently vary from NH to NH, participants recommended that the entire state use the same form. They recommended that the transfer form be useful in both directions by including a section for the ED provider to complete to support the ED-to-NH transition. Participants suggested that systems use a transfer checklist to help ensure that all processes occur as expected. They strongly recommended verbal communication across care settings to complement written communication and to improve on deficiencies that occur with transfer form-only strategies. Notably, participants suggested that the different care sites engage in relationship-building efforts to improve compliance with recommendations (eg, form completion) and collaborative problem solving. Participants advised additional structure to NH-ED care transitions, similar to hospital-to-hospital transfers, that includes a 2-way, statewide transfer form; a checklist; and verbal communication.

A Multifaceted Intervention to Implement Guidelines Did Not Affect Hospitalization Rates for Nursing Home–Acquired Pneumonia

Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home-acquired pneumonia (NHAP) affected hospitalization rates. Quasi-experimental, mixed-methods, multifaceted, unblinded intervention trial. Sixteen nursing homes (NHs) from 1 corporation: 8 in metropolitan Denver, CO; 8 in Kansas and Missouri during 3 influenza seasons, October to April 2004 to 2007. Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI); NH staff and physicians were eligible. Multifaceted, including academic detailing to clinicians, within-facility nurse change agent, financial incentives, and nursing education. Subjects' NH medical records were reviewed for resident characteristics, disease severity, and care processes. Bivariate analysis compared hospitalization rates for subjects with stable and unstable vital signs between intervention and control NHs and time periods. Qualitative interviews were analyzed using content coding. Hospitalization rates for stable residents in both NH groups remained low throughout the study. Few critically ill subjects in the intervention NHs were hospitalized in either the baseline or intervention period. In control NHs, 8.7% of subjects with unstable vital signs were hospitalized during the baseline and 33% in intervention year 2, but the difference was not statistically significant (P = .10). Interviews with nursing staff and leadership confirmed there were significant pressures for, and enablers of, avoiding hospitalization for treatment of acute infections. Secular pressures to avoid hospitalization and the challenges of reaching NH physicians via academic detailing are likely responsible for the lack of intervention effect on hospitalization rates for critically ill NH residents.

The Practice of Continuous Palliative Sedation in Elderly Patients: A Nationwide Explorative Study Among Dutch Nursing Home Physicians

To study the practice of continuous palliative sedation (CPS) by Dutch nursing home physicians in 2007. A structured retrospective questionnaire. Nationwide nursing home physician study in the Netherlands. One thousand two hundred fifty-four nursing home physicians received a questionnaire concerning their last case of CPS in 2007; 54% (n=675) responded. Characteristics of CPS and requests for euthanasia were measured. Three hundred sixteen patients were described. The majority had cancer or dementia. The most-reported refractory symptoms were pain (52%), anxiety (44%), exhaustion (44%), dyspnea (40%), delirium (24%), loss of dignity (18%), and existential distress (16%). In 98% of cases, CPS was aimed at symptom relief. Of patients with cancer, 17% had previously requested euthanasia. The mean starting dose of midazolam was 31 mg every 24 hours (range 0-240 mg/24 h), and the mean end dose was 48 mg every 24 hours (range 0-480 mg/24 h). In addition to physical symptoms, anxiety, exhaustion, loss of dignity, and existential distress are often mentioned as refractory symptoms in the decision to start CPS by nursing home physicians. Furthermore, close to one in five patients with cancer had made a previous request for euthanasia. The dosage range of midazolam in this study fits the recommendations of the Dutch national guideline on palliative sedation, although international studies show smaller dosage ranges. Finally, prospective research about the acceptability and assessment of nonphysical symptoms as indications for CPS is recommended.

Medical Conditions of Nursing Home Admissions

BackgroundAs long-term nursing home care is likely to increase with the aging of the population, identifying chronic medical conditions is of particular interest. Although need factors have a strong impact on nursing home (NH) admission, the diseases causing these functional disabilities are lacking or unclear in the residents' file. We investigated the medical reason (primary diagnosis) of a nursing home admission with respect to the underlying disease.MethodsThis study is based on two independent, descriptive and comparative studies in Belgium and was conducted at two time points (1993 and 2005) to explore the evolution over twelve years. Data from the subjects were extracted from the resident's file; additional information was requested from the general practitioner, nursing home physician or the head nurse in a face-to-face interview. In 1993 we examined 1332 residents from 19 institutions, and in 2005 691 residents from 7 institutions. The diseases at the time of admission were mapped by means of the International Classification of Diseases - 9th edition (ICD-9). Longitudinal changes were assessed and compared by a chi-square test.ResultsThe main chronic medical conditions associated with NH admission were dementia and stroke. Mental disorders represent 48% of all admissions, somatic disorders 43% and social/emotional problems 8%. Of the somatic disorders most frequently are mentioned diseases of the circulatory system (35%) [2/3 sequels of stroke and 1/5 heart failure], followed by diseases of the nervous system (15%) [mainly Parkinson's disease] and the musculoskeletal system (14%) [mainly osteoarthritis]. The most striking evolution from 1993 to 2005 consisted in complicated diabetes mellitus (from 4.3 to 11.4%; p < 0.0001) especially with amputations and blindness. Symptoms (functional limitations without specific disease) like dizziness, impaired vision and frailty are of relevance as an indicator of admission.ConclusionDiseases like stroke, diabetes and mobility problems are only important for institutionalisation if they cause functional disability. Diabetes related complications as cause of admission increased almost three-fold between 1993 and 2005.

Impact of NHAP Guideline Implementation Intervention on Staff and Resident Vaccination Rates

Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home acquired pneumonia (NHAP), including influenza and pneumococcal vaccination, improves resident subject and staff vaccination rates. Quasi-experimental, mixed-methods multifaceted intervention trial conducted at 16 nursing homes (NHs) from 1 corporation (8 in metropolitan Denver, Colorado; 8 in Kansas and Missouri) during 3 influenza seasons, October to April 2004 to 2007. Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI) and NH staff and physicians were eligible. Subjects' NH records were reviewed for vaccination. Each director of nursing (DON) completed a questionnaire assessing staffing and the number of direct care staff vaccinated against influenza. DONs and study liaison nurses were interviewed after the intervention. Bivariate analysis compared vaccination outcomes and covariates between intervention and control homes, and risk-adjusted models were fit. Qualitative interview transcripts were analyzed using content coding. No statistically significant relationship between the intervention and improved resident vaccination rates was found, so other factors associated with improved rates were explored. Estimated direct patient care staff vaccination rates were better during the baseline and improved more in the intervention NHs. Qualitative results suggested that facility-specific factors and national policy changes impacted vaccination rates. External factors influence staff and resident vaccination rates, diluting the potential impact of a comprehensive program to improve care for NHAP on vaccination.

Effects of a multi-faceted program to increase influenza vaccine uptake among health care workers in nursing homes: A cluster randomised controlled trial

Despite the recommendation of the Dutch association of nursing home physicians (NVVA) to be immunized against influenza, vaccine uptake among HCWs in nursing homes remains unacceptably low. Therefore we conducted a cluster randomised controlled trial among 33 Dutch nursing homes to assess the effects of a systematically developed multi-faceted intervention program on influenza vaccine uptake among HCWs. The intervention program resulted in a significantly higher, though moderate, influenza vaccine uptake among HCWs in nursing homes. To take full advantage of this measure, either the program should be adjusted and implemented over a longer time period or mandatory influenza vaccination should be considered.

Causes of persistent dizziness in elderly patients in primary care.

Although dizzy patients are predominantly seen in primary care, most diagnostic studies on dizziness have been performed among patients in secondary or tertiary care. Our objective was to describe subtypes of dizziness in elderly patients in primary care and to assess contributory causes of dizziness. We performed a cross-sectional diagnostic study among elderly patients in the Netherlands consulting their family physician for persistent dizziness. All patients underwent a comprehensive evaluation according to a set of diagnostic tests that were developed during an international Delphi procedure. Data for each patient were independently reviewed by a panel consisting of a family physician, a geriatrician, and a nursing home physician, which resulted in major and minor contributory causes of dizziness. From June 2006 to January 2008, we included 417 patients aged 65 to 95 years. Presyncope was the most common dizziness subtype (69%). Forty-four percent of the patients were assigned more than 1 dizziness subtype. Cardiovascular disease was considered to be the most common major contributory cause of dizziness (57%), followed by peripheral vestibular disease (14%), and psychiatric illness (10%). An adverse drug effect was considered to be the most common minor contributory cause of dizziness (23%). Sixty-two percent of the patients were assigned more than 1 contributory cause of dizziness. Contrary to most previous studies, cardiovascular disease was found to be the most common major cause of dizziness in elderly patients in primary care. In one-quarter of all patients an adverse drug effect was considered to be a contributory cause of dizziness, which is much higher than reported in previous studies.

New AMDA President Advocates a Long-Term Care Medical Specialty

New AMDA President Advocates a Long-Term Care Medical Specialty

Patient focused drug surveillance of elderly patients in nursing homes

To examine whether patient focused drug surveillance was associated with a higher quality of drug treatment at nursing homes. An intervention study in four nursing homes in Sweden and four other nursing homes served as controls. At the intervention nursing homes physicians focused on patients' health status as a baseline for further ongoing medication. The outcomes were mortality, health care consumption, and number of drugs, health status and evaluations as parameters for "quality of drug treatment". There were no significant differences in mortality rates. Health care consumption and polypharmacy were extensive in both groups. There was a significant reduction of number of drugs used per patient at the intervention homes during the study (p < 0.05). Monitoring and evaluation of the effects of medications were significantly more frequent at the intervention homes (p < 0.01). The intervention resulted in significant positive results in relation to "quality of drug treatment", a shift in health care utilization with concomitant use of fewer drugs. The study showed an extreme shortage of monitoring of health status and surveillance of the effects of drugs in the elderly.

Nursing Home Physicians Could Get Fee Hike

Nursing Home Physicians Could Get Fee Hike

Definition of infection in chronic wounds by Dutch nursing home physicians

In the above paper, the following errors appeared: On page 267, abstract, line 7, the sentence was, ‘All NHPs treated three or less chronic post-surgical wounds, whereas 68.4% treated none.’ This should have read, ‘Of the responding NHPs, 31.6 % treated at least one, but never more than two chronic post surgical wounds , whereas 68.4% of the NHPs treated none.’ On page 269, column 2, line 2, the sentence was ‘All NHPs treated three or less chronic postsurgical wounds, whereas 68.4% of the NHPs treated none (Table 1).’ This should have read, ‘Of the responding NHPs, 31.6 % treated at least one, but never more than two chronic post surgical wounds, whereas 68.4% of the NHPs treated none (Table 1).’ On page 269 column 2, line 10, the sentence was ‘Of the NHPs, 97.4% treated one or less chronic VLU, whereas 76.9% treated none (Table 1), and 88.1% of the NHPs considered none of the treated chronic VLU to be infected (Table 2).’ This should have read, ‘Of the responding Dutch NHPs, 17% actually treated at least one, but no more than two chronic arterial ulcers whereas 82.9% treated none (Table 1). 90.5% of the NHPs considered none of the arterial ulcers to be infected (Table 2).’ On page 269 column 2, line 16, the sentence was ‘Many NHPs (94.9%) treated one or less chronic diabetic ulcer, whereas 80.2% treated none (Table 1).’ This should have read, ‘Of the responding Dutch NHPs 19.9% actually treated at least one, but no more than three chronic diabetic ulcers, whereas 80.2% treated none (Table 1).’ We would like to apologize for these errors.

Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care?

Letters15 September 2009Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care?Heidi K. White, MD, MHS, Gwendolen Buhr, MD, MHS, and Jose Gonzalez, MD, on behalf of the North Carolina Medical Directors AssociationHeidi K. White, MD, MHSFrom Duke University School of Medicine, Durham, NC 27701, and Extended Care Physicians, Asheville, NC 28802.Search for more papers by this author, Gwendolen Buhr, MD, MHSFrom Duke University School of Medicine, Durham, NC 27701, and Extended Care Physicians, Asheville, NC 28802.Search for more papers by this author, and Jose Gonzalez, MDFrom Duke University School of Medicine, Durham, NC 27701, and Extended Care Physicians, Asheville, NC 28802.Search for more papers by this author, on behalf of the North Carolina Medical Directors AssociationSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-6-200909150-00012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:We read with interest the article by Katz and colleagues (1). The nursing home in the United States and other countries has a heterogeneous population of short-stay and long-stay residents. Short-stay residents include persons who come for rehabilitation after a hospital admission, for respite stays, and for palliative or end-of-life care. Long-stay residents include persons with cognitive, physical, or a combination of impairments that require extensive assistance with activities of daily living. Providing excellent care to these persons requires extensive knowledge not only of chronic disease management, acute disease management, and geriatric syndromes, but also of the ...Reference1. Katz PR, Karuza J, Intrator O, Mor V. Nursing home physician specialists: a response to the workforce crisis in long-term care. Ann Intern Med. 2009;150:411-3. [PMID: 19293074] LinkGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Duke University School of Medicine, Durham, NC 27701, and Extended Care Physicians, Asheville, NC 28802.Disclosures: None disclosed. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoNursing Home Physician Specialists: A Response to the Workforce Crisis in Long-Term Care Paul R. Katz , Jurgis Karuza , Orna Intrator , and Vincent Mor Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care? Leslie S. Libow and Gisele Wolf-Klein Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care? William B. Freedberg Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care? Paul R. Katz , Jurgis Karuza , and Vincent Mor Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care? Cheryl L. Phillips Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care? Marie-Luz Villa Metrics 15 September 2009Volume 151, Issue 6Page: 430-431KeywordsDementiaHealth care qualityLong-term careMedical staffMotivationNursesNursing homesPatientsPhysiciansQuality improvement ePublished: 15 September 2009 Issue Published: 15 September 2009 CopyrightCopyright © 2009 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...

Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care?

Letters15 September 2009Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care?William B. Freedberg, MD, PhDWilliam B. Freedberg, MD, PhDFrom Tufts University, Baystate Medical Center, Springfield, MA 01199.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-6-200909150-00014 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:As a partly retired, board-certified internist and geriatrician who has spent most of the past dozen years caring for patients in the nursing home setting, I was very interested to read the recent article by Katz and colleagues (1). More than 80% of my “evaluation and management” encounters in a typical month are for patients in nursing homes, including subacute care, long-term care, or hospice. I wish to offer some comments.First, do we really need another specialty type of certification, with more examinations, more requirements, more paperwork, and more fees and its own small bureaucracy to ...Reference1. Katz PR, Karuza J, Intrator O, Mor V. Nursing home physician specialists: a response to the workforce crisis in long-term care. Ann Intern Med. 2009;150:411-3. [PMID: 19293074] LinkGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Tufts University, Baystate Medical Center, Springfield, MA 01199.Disclosures: None disclosed. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoNursing Home Physician Specialists: A Response to the Workforce Crisis in Long-Term Care Paul R. Katz , Jurgis Karuza , Orna Intrator , and Vincent Mor Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care? Paul R. Katz , Jurgis Karuza , and Vincent Mor Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care? Cheryl L. Phillips Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care? Marie-Luz Villa Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care? Heidi K. White , Gwendolen Buhr , Jose Gonzalez , and Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care? Leslie S. Libow and Gisele Wolf-Klein Metrics 15 September 2009Volume 151, Issue 6Page: 431-432KeywordsConflicts of interestElderlyGeriatricsHospitalistsLong-term careNursesNursing homesPatients ePublished: 15 September 2009 Issue Published: 15 September 2009 CopyrightCopyright © 2009 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...

Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care?

Letters15 September 2009Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care?Cheryl L. Phillips, MD, CMDCheryl L. Phillips, MD, CMDFrom On Lok Lifeways, San Francisco, CA 94109.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-6-200909150-00010 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:Katz and colleagues (1) present a provocative and appealing model to address the challenge of attracting committed and trained physicians into nursing home care. The barriers to such practice are already assumed. In a 2006 report, Katz and Karuza (2) noted that only 1 in 5 physicians who were identified as primary care physicians reported any involvement in nursing home care, and that those who were involved averaged only about 2 hours per week. Furthermore, the 2005 survey of the American Medical Directors Association (AMDA) (3), the national association of approximately 4000 nursing home medical directors, found ...

Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care?

Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care?