US Nurses Research Articles

The Role of Organizational Slack and Human Capital in Managing Performance Shocks: How US Nursing Homes Buffered Hurricane Katrina

Public service organizations employ buffers to ward off disruptive performance shocks such as natural disasters, budget cuts, and uncertain events. Existing applications on buffering focus on how slack human resources are reallocated to high-risk areas during times of uncertainty to dampen the impact these events have on core organizational processes. Besides slack, the quality of human capital is also important. Skilled personnel have the technical acumen and expertise to help managers navigate through treacherous times and still deliver public services. Yet, existing work does not test the impact of these two buffers simultaneously. Using a panel dataset of nursing homes in Louisiana and Mississippi, I explore how personnel slack and human capital helped absorb the devastation of Hurricane Katrina. The findings suggest that human capital buffers the impact of Hurricane Katrina on health deficiencies and physical dependency. In contrast, slack capacity amplifies the impact of Katrina on health deficiencies.

A 15-Year Trend Study of Internationally Educated Nurses' NCLEX-RN Performance.

The aim of the study was to describe trends in internationally educated nurses' (IEN) National Council Licensure Examination-Registered Nurses (NCLEX®-RN) performance from 2003 to 2017 and to determine the odds of passing the exam based on country of nursing education. IEN comprise 5.6 percent of US nurses; more than half come from the Philippines. There is a lack of research on IEN NCLEX-RN performance. Correlational research was used to determine the performance and likelihood of passing the NCLEX-RN based on country of nursing education using secondary data analysis. Odds ratios were estimated to express the odds of passing. IEN NCLEX-RN applications and pass rates are decreasing. The odds of passing the NCLEX-RN among Philippine-educated nurses are lower compared to all other IEN. The odds of passing the Canadian NCLEX-RN are higher for all IEN. The low NCLEX-RN pass rate of IEN reflects differences in nursing education and practice across countries.

Attitudes and knowledge about cannabis and cannabis-based therapies among US neurologists, nurses, and pharmacists

Use of cannabinoid therapies is on the rise in the United States, but responses of healthcare professionals and their knowledge of these therapies have been mixed. More information is needed about factors associated with healthcare professionals' attitudes and knowledge about medical cannabis. We conducted an online survey of US-based neurologists, nurse practitioners (NPs)/nurses, and pharmacists in August–September of 2018 (n = 451). We constructed perceived knowledge and attitudes scales and a knowledge index from multiple items and assessed state cannabis laws, participant's sociodemographics, workplace type and policies, and patient population. We used ordinary least-squares regression to examine associations among study variables. Over 80% of participants supported use and legalization of medical cannabis, especially cannabidiol (CBD) for epilepsy and when prescribed by a medical provider, but 40–50% (depending on item) felt unfamiliar with cannabinoid pharmacology and clinical applications. A total of 43% favored legal recreational cannabis. Pharmacists scored higher on the knowledge test than neurologists and NPs/nurses, but NPs/nurses had more favorable attitudes than neurologists and higher perceived knowledge than pharmacists. Both knowledge indicators predicted attitudes. State cannabis access and favorable workplace policies were associated with higher knowledge and more favorable attitudes. Healthcare professionals see potential in cannabis therapies but report significant knowledge gaps. Professional cannabinoid education is needed to address growing patient and provider demand for knowledge about cannabinoid therapies.

The Mediterranean diet, plasma metabolome, and cardiovascular disease risk.

To investigate whether metabolic signature composed of multiple plasma metabolites can be used to characterize adherence and metabolic response to the Mediterranean diet and whether such a metabolic signature is associated with cardiovascular disease (CVD) risk. Our primary study cohort included 1859 participants from the Spanish PREDIMED trial, and validation cohorts included 6868 participants from the US Nurses' Health Studies I and II, and Health Professionals Follow-up Study (NHS/HPFS). Adherence to the Mediterranean diet was assessed using a validated Mediterranean Diet Adherence Screener (MEDAS), and plasma metabolome was profiled by liquid chromatography-tandem mass spectrometry. We observed substantial metabolomic variation with respect to Mediterranean diet adherence, with nearly one-third of the assayed metabolites significantly associated with MEDAS (false discovery rate < 0.05). Using elastic net regularized regressions, we identified a metabolic signature, comprised of 67 metabolites, robustly correlated with Mediterranean diet adherence in both PREDIMED and NHS/HPFS (r = 0.28-0.37 between the signature and MEDAS; P = 3 × 10-35 to 4 × 10-118). In multivariable Cox regressions, the metabolic signature showed a significant inverse association with CVD incidence after adjusting for known risk factors (PREDIMED: hazard ratio [HR] per standard deviation increment in the signature = 0.71, P < 0.001; NHS/HPFS: HR = 0.85, P = 0.001), and the association persisted after further adjustment for MEDAS scores (PREDIMED: HR = 0.73, P = 0.004; NHS/HPFS: HR = 0.85, P = 0.004). Further genome-wide association analysis revealed that the metabolic signature was significantly associated with genetic loci involved in fatty acids and amino acids metabolism. Mendelian randomization analyses showed that the genetically inferred metabolic signature was significantly associated with risk of coronary heart disease (CHD) and stroke (odds ratios per SD increment in the genetically inferred metabolic signature = 0.92 for CHD and 0.91 for stroke; P < 0.001). We identified a metabolic signature that robustly reflects adherence and metabolic response to a Mediterranean diet, and predicts future CVD risk independent of traditional risk factors, in Spanish and US cohorts.

Facebook recruitment of nurses as research participants: Methodological considerations

• Use of Facebook nursing interest group pages is a rapid, cost-effective method to recruit nurses for survey research • Facebook recruited samples of US nurses tend to be younger and less clinically experienced • Rapid sample recruitment needs to be balanced with strategies to achieve sample representativeness • We present a standardized framework for Facebook recruitment methodological decision-making and reporting

Call to Action for a US Nurse General: From Ebola to Corona.

Author Affiliation: Nursing Research Consultant, Karen Gabel Speroni Consultation LLC, Leesburg, Virginia. The author declares no conflicts of interest. Correspondence: Dr Speroni ([email protected]).

Health Data Sharing in US Nursing Homes: A Mixed Methods Study

Objectives(1) To understand the extent to which nursing homes have the capability for data sharing and (2) to explore nursing home leaders' perceptions of data sharing with other health care facilities and with residents and family members. DesignExploratory, mixed-methods. Setting and ParticipantsWe conducted a secondary analysis of data from a national survey of nursing home administrative leaders (n = 815) representing every state in the United States. Next, semistructured interviews were used to elicit rich contextual information from (n = 12) administrators from nursing homes with varying data-sharing capabilities. MethodsWe used descriptive statistics along with Rao-Scott chi-square and logistic regression models to examine the relationship between health data–sharing capabilities and nursing home characteristics such as location, bed size, and type of ownership. Qualitative data were analyzed using content analysis. ResultsOf the 815 nursing homes completing the survey, 95% had computerized (electronic) medical records, and 46% had some capability for health information exchange. Nursing homes located in metropolitan areas had 2.53 (95% confidence interval = 1.53, 4.18) times greater odds for having health information exchange capability compared with nursing homes in small towns. Perceived challenges to health data sharing with residents and family members and external clinical partners include variance in systems and software, privacy and security concerns, and organizational factors slowing uptake of technology. Perceived benefits of health data sharing included improved communication, improved care planning, and anticipating future demand. Conclusions and ImplicationsAs health data sharing becomes more ubiquitous in acute care settings, policy makers, nursing home leaders, and other stakeholders should prepare by working to mitigate barriers and capitalize on potential benefits of implementing this technology in nursing homes.

Beyond Resilience and Burnout: The Need for Organizational Change to Promote Humanistic Practice and Teaching in Healthcare

Rapid changes in healthcare organization and practice environments, increasingly driven by business models and commercial interests, are associated with widespread burnout and dissatisfaction among healthcare professionals and pose barriers to humanistic relationship-centered quality care. Studies show burnout and significant stress currently affect over half of US physicians and nurses. Clinicians’ ability to provide compassionate care is significantly challenged. Most solutions to date have included individual interventions designed to enhance well-being and promote resilience. We examined organizational factors that inhibit or promote humanistic practice by faculty physicians in today’s healthcare environment. In this qualitative study, physician faculty who completed a one-year faculty development program in humanism at eight US academic medical centers provided written answers to two open-ended questions: a) What institutional or specific organizational unit-related factors promote humanism for you and others? b) What institutional or specific organizational unit-related factors inhibit or pose barriers, to humanism for you and others? 74% (68/92) of the physicians participated. The constant comparative method was used to analyze responses. We found that organizational culture was the central theme. Motivators of humanism included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities promoting humanism, and practice structures that facilitate humanism. Factors that inhibited humanism included “top down” organizational culture, non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures. Our findings suggest that organizational culture is, at a minimum, equally important as individual interventions. We describe features of organizational culture that reinforce humanistic practice and care in healthcare institutions and offer recommendations for organizational change that support the primacy of humanistic, compassionate, high quality patient care.

US Physician and Nurse Proclivity to Refer Their Patients Into Clinical Trials.

Clinical research awareness, familiarity, referral proclivity, and practice have been assessed to varying degrees among US-based physicians specializing in oncology but very few studies have assessed these attitudes and behaviors among US physicians and nurses outside of oncology. To address this gap, the Tufts Center for the Study of Drug Development (Tufts CSDD) conducted a study of 589 US-based physicians and 1255 US-based nurses. US health care providers have very limited exposure to clinical research in medical and nursing school and in professional meetings. Very high percentages of multispecialty nurses and doctors view clinical trials as health care options, are interested in referring their patients into appropriate clinical trials, and are comfortable providing clinical trial information to, and discussing clinical trial opportunities with, their patients. Yet US physicians and nurses refer very small numbers of patients each year largely because of the inability to access clinical trial information, and the lack of sufficient information and time to evaluate and confidently discuss clinical trial options with their patients. Several factors are predictors of referral behavior, including proximity to research activity and past involvement in clinical research as an investigator, study coordinator, or study volunteer. The results of this study offer new insights into addressing low referral rates among US health care providers.

Suicidal Ideation in US Nursing Homes: Association With Individual and Facility Factors

To assess prevalence of suicidal ideation (SI) among new postacute and long-stay nursing home (NH) admissions and examine the associations with individual and NH-level factors. A total of 1,864,102 postacute and 304,106 long-stay admissions to just over 15,000 NHs between 7/1/2014 and 6/30/2015. Using 100% of the national Minimum Data Set 3.0, we identified SI and key covariates. SI was based on responses to one item on the PHQ-9 scale. For postacute residents, SI was measured at admission and discharge. For long-stay residents, SI was assessed at admission and assessments closest to 90, 180, and 365 days thereafter. Patient sociodemographics, functional and cognitive status, comorbid conditions, and other covariates were included as independent variables, as were several NH-level factors. Logistic regression models were fit to estimate SI risk at admission and at subsequent time intervals. Observed 2-week prevalence rates of SI were highest at admission (1.24% for postacute and 1.84% for long stays) and declined thereafter at each subsequent time interval. The odds of SI were significantly increased for residents with severe depression at admission and all subsequent intervals. Residents in for-profits had significantly lower rates of SI, compared with those in not-for-profits. Our findings demonstrate that SI risk in NHs is highest at admission and subsequently declines. We found several potentially modifiable individual-level risk factors for SI. The identification of SI may be seriously underreported in for-profit-facilities. Future research may be needed to explore how the PHQ-9 item on SI is understood by residents and recorded by staff.

Stigma and US Nurses' Intentions to Provide the Standard of Maternal Care to Incarcerated Women, 2017.

Objectives. To examine relationships among actionable drivers and facilitators of stigma and nurses' intentions to provide the standard of maternal care recommended by the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) for incarcerated women.Methods. We conducted a Web-based survey of perinatal nurses in the United States (n = 665; participation rate 98.0%; completion rate 95.3%) in July through September 2017. We used multivariable logistic regression to predict higher than median intentions to provide the standard of care.Results. Lower stigmatizing individual attitudes and institutional norms and higher perceived autonomy when caring for an incarcerated woman were significantly associated with higher care intentions. Knowledge of the AWHONN position statement on the standard of care or their own state's shackling laws was not associated with higher care intentions.Conclusions. We documented significant associations among actionable drivers and facilitators of stigma and the intentions of a key health care provider group to deliver the standard of maternal care to incarcerated women. Individual- and institutional-level stigma-reduction interventions may increase the quality of maternal care and improve perinatal outcomes for women who give birth while incarcerated.

Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations

Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population. To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017-before and after the introduction of national initiatives to reduce hospitalizations. In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019. The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained. The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%). The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.

Changes in US Nursing Home Infection Prevention and Control Programs From 2014 to 2018

ObjectiveBurgeoning rates of antibiotic resistance have resulted in a shift in national focus to improve infection prevention and control programs in US nursing homes (NHs). We sought to evaluate the changes in nursing home infection prevention and control programs over time. DesignRetrospective comparative analysis of national nursing home survey data from 2014 and 2018. Setting and participantsWe used survey data from 2 nationally representative samples of US nursing homes (945 NHs in 2014 and 888 in 2018). MethodsThree indices measuring antibiotic stewardship, outbreak control, and urinary tract infection prevention (ranging from 0 to 100) were developed to measure the change in infection prevention and control programs. Multivariable linear regression models were used to identify facility and infection preventionist characteristics associated with each index. Decomposition models were used to identify contributions of factors on the differences in each index over time. ResultsFrom 2014 to 2018, we saw strengthening of antibiotic stewardship practices by 33 percentage points, outbreak control practices by 13 percentage points, and urinary tract infection prevention practices by 6 percentage points. Although we found several predictors of these improvements, much of the improvement was due to the difference in time. Conclusions and ImplicationsPolicy mandates and greater national attention are likely important factors in improving nursing home infection prevention and control practices. Further work is needed to evaluate the effect of these programs on resident outcomes.

The Prevalence and Factors Associated with Antiepileptic Drug Use in US Nursing Home Residents.

Antiepileptic drugs (AEDs) are commonly used by nursing home residents, both on- and off-label. The landscape of AED use has changed over the past two decades; however, despite this, contemporaneous research on AED use in US nursing home residents is scant. The aim of this study was to estimate the prevalence of AED use, describe prescribing patterns, identify factors associated with AED use, and assess whether these factors differ among AEDs with expanded indications in older adults (i.e. gabapentin, pregabalin, topiramate, and lamotrigine). We conducted a cross-sectional study among 549,240 long-stay older residents who enrolled in fee-for-service Medicare and lived in 15,111 US nursing homes on 1 September 2016. Demographics and conditions associated with AED indications, epilepsy comorbidities, and safety data came from the Minimum Data Set Version 3.0 (MDS 3.0). Medicare Part D claims were used to identify AED use. Robust Poisson models and multinomial logistic models for clustered data estimated adjusted prevalence ratios (aPR), adjusted odds ratios (aOR), and 95% confidence intervals (CIs). Overall, 24.0% used AEDs (gabapentin [13.3%], levetiracetam [4.7%], phenytoin [1.9%], pregabalin [1.8%], and lamotrigine [1.2%]). AED use was associated with epilepsy (aPR 3.73, 95% CI 3.69-3.77), bipolar disorder (aPR 1.20, 95% CI 1.18-1.22), pain (aPRmoderate/severe vs. no pain 1.42, 95% CI 1.40-1.44), diabetes (aPR 1.27, 95% CI 1.26-1.28), anxiety (aPR 1.12, 95% CI 1.11-1.13), depression (aPR 1.17, 95% CI 1.15-1.18), or stroke (aPR 1.08, 95% CI 1.06-1.09). Residents with advancing age (aPR85+ vs. 65-74years 0.73, 95% CI 0.73-0.74), Alzheimer's disease/dementia (aPR 0.87, 95% CI 0.86-0.88), or cognitive impairment (aPRsevere vs. no impairment 0.62, 95% CI 0.61-0.63) had decreased AED use. Gabapentinoid use was highly associated with pain (aORmoderate/severe vs. no pain 2.07, 95% CI 2.01-2.12) and diabetes (aOR 1.79, 95% CI 1.76-1.82), but not with an epilepsy indication. AED use was common in nursing homes, with gabapentin most commonly used (presumably for pain). That multiple comorbidities were associated with AED use underscores the need for future studies to investigate the safety and effectiveness of AED use in nursing home residents.

The Constant Caregiver: Work–family Spillover among Men and Women in Nursing

Work–family spillover is a central concept in the work and occupations literature, with prior research detailing its negative outcomes and gendered dimensions. With increased demands for careworkers and more men entering occupations such as nursing, we examine experiences and perceptions of spillover using qualitative data from a diverse sample of 48 US nurses. We find similarities across men and women in terms of exhaustion and stress as well as in anticipating spillover in their careers. Yet, we also find some differences, with men (but not women) highlighting the transfer of emotional capital between work and family. We extend work–family research by broadening the concept of spillover to include its anticipation and the transfer of emotional capital – both aspects that have been previously under-examined. These findings have implications for the retention and support of careworkers and refine the concept of spillover in ways that could apply to various employment sectors.

Iron Consumption Is Not Consistently Associated with Fecundability among North American and Danish Pregnancy Planners

Infertility is an important public health problem with few known modifiable risk factors. Dietary factors including folic acid have been associated with improved fertility, but the association between iron and fertility is understudied. One study among US nurses found a 40% lower risk of ovulatory infertility with higher intake of nonheme iron and iron supplements. The aim of this study was to determine the extent to which iron intake from diet and supplements reported on structured questionnaires is associated with fecundability. We conducted parallel analyses that used data from 2 prospective cohort studies of pregnancy planners from Denmark (Snart Foraeldre; n=1693) and North America (PRESTO; n=2969) during 2013-2018. Follow-up comprised menstrual cycles at risk until pregnancy or censoring for fertility treatment, stopped trying to conceive, withdrawal, loss to follow-up, or 12 cycles of attempt. We used proportional probabilities regression models to estimate fecundability ratios (FRs) and 95% CIs, adjusting for confounders. We found little association between dietary heme iron intake and fecundability in either cohort. The FR for nonheme iron intake (≥11 mg/d compared with <9 mg/day) was 1.11 for Snart Foraeldre participants (95% CI: 0.92, 1.34) and 1.01 for PRESTO participants (95% CI: 0.89, 1.14). The FR for iron-containing supplements was 1.01 in Snart Foraeldre (95% CI: 0.90, 1.13) and 1.19 in PRESTO (95% CI: 1.03, 1.38). In PRESTO, but not Snart Foraeldre, stronger positive associations were found for nonheme iron intake and iron supplement use among women with heavy menses or short menstrual cycles. Overall, dietary intake of iron was not consistently associated with fecundability, although there was some evidence for a positive association among women with risk factors for iron deficiency. We also found a small positive association between supplemental iron intake and fecundability among North American, but not Danish, pregnancy planners.

Optimizing Drug Therapies in Patients with COPD in the US Nursing Home Setting.

Chronic obstructive pulmonary disease (COPD) can be a disabling disease, and the impact on older adults is particularly evident in the nursing home setting. Chronic obstructive pulmonary disease is present in about 20% of nursing home residents, most often in women, and accounts for significant healthcare utilization including acute care visits for exacerbations and pneumonia, as well as worsening heart disease and diabetes mellitus. The emphasis on hospital readmissions is particularly important in nursing homes where institutions have quality measures that have financial implications. Optimizing drug therapies in individuals with COPD involves choosing medications that not only improve symptoms, but also decrease the risk of exacerbations. Optimizing the treatment of comorbidities such as heart disease, infections, and diabetes that may affect COPD outcomes is also an important consideration. Depending on the nursing home setting and the patient, the options for optimizing COPD drug therapies may be limited owing to patient-related factors such as cognition and physical impairment or available resources, primarily reimbursement-related issues. Choosing the best drug therapy for COPD in older adults is limited by the difficulty in assessing respiratory symptoms using standardized assessment tools and potentially decreased inspiratory ability of frail individuals. Because of cognitive and physical impediments, ensuring optimal delivery of inhaled medications into the lungs has significant challenges. Long-acting bronchodilators, inhaled corticosteroids, and roflumilast decrease the risk of exacerbations, although inhaled corticosteroids should be used judiciously in this population because of the risk of pneumonia and oropharyngeal side effects. Treatment of COPD exacerbations should occur early and consideration should be made to the benefits and risks of systemic corticosteroids and antibiotics. Clinical research in the COPD population in nursing homes is clearly lacking, and ripe for discovery of effective management strategies.

Becoming and being an environmentally ‘woke’ nurse: A phenomenological study

BackgroundIncreasing numbers of nurses view environmental activism as part of their role. No studies have explored the reasons. AimThis study aimed to identify what awakened and shaped US and UK nurses’ environmental activism. DesignA Gadamerian hermaneutic phenomenological study. MethodsForty nurses were recruited in 2017 using purposive sampling (USA n = 23, UK n = 17). Four focus groups were followed by individual interviews. Iterative, fully immersive phenomenological analysis was conducted with corroboration of themes and a final “shared horizon.” FindingsParticipants described “lightbulb” events whereby they recognized environmental threats to people and the planet. Their nursing-centered values of social justice, generational fairness, and alleviating suffering underpinned a shared belief in their ability to help mitigate those threats. They believed it was their duty as nurses to take action on behalf of individuals, communities, and the planet. DiscussionThe nursing skill set of these nurses makes for effective leadership and environmental activism. Environmentally “woke” nurses have the skills to create solutions and systems approaches that increase sustainability, improve health and make a difference to people's lives, now and for future generations.

US Physician and Nurse Proclivity to Refer Their Patients Into Clinical Trials

Clinical research awareness, familiarity, referral proclivity, and practice have been assessed to varying degrees among US-based physicians specializing in oncology but very few studies have assessed these attitudes and behaviors among US physicians and nurses outside of oncology. To address this gap, the Tufts Center for the Study of Drug Development (Tufts CSDD) conducted a study of 589 US-based physicians and 1255 US-based nurses. US health care providers have very limited exposure to clinical research in medical and nursing school and in professional meetings. Very high percentages of multispecialty nurses and doctors view clinical trials as health care options, are interested in referring their patients into appropriate clinical trials, and are comfortable providing clinical trial information to, and discussing clinical trial opportunities with, their patients. Yet US physicians and nurses refer very small numbers of patients each year largely because of the inability to access clinical trial information, and the lack of sufficient information and time to evaluate and confidently discuss clinical trial options with their patients. Several factors are predictors of referral behavior, including proximity to research activity and past involvement in clinical research as an investigator, study coordinator, or study volunteer. The results of this study offer new insights into addressing low referral rates among US health care providers.

Incidence of Lower-Extremity Fractures in US Nursing Homes.

Limited studies suggest lower-extremity (LE) fractures are morbid events for nursing home (NH) residents. Our objective was to conduct a nationwide study comparing the incidence and resident characteristics associated with hip (proximal femur) vs nonhip LE (femoral shaft and tibia-fibula) fractures in the NH. Retrospective cohort study. US NHs. We included all long-stay residents, aged 65 years or older, enrolled in Medicare from January 1, 2008, to December 31, 2009 (N = 1 257 279). Residents were followed from long-stay qualification until the first event of LE fracture, death, or end of follow-up (2 years). Fractures were classified using Medicare diagnostic and procedural codes. Function, cognition, and medical status were obtained from the Minimum Data Set prior to long-stay qualification. Incidence rates (IRs) were calculated as the total number of fractures divided by person-years. During 42 800 person-years of follow-up, 52 177 residents had an LE fracture (43 695 hip, 6001 femoral shaft, 2481 tibia-fibula). The unadjusted IRs of LE fractures were 1.32/1000 person-years (95% confidence interval [CI] = 1.27-1.38) for tibia-fibula, 3.20/1000 person-years (95% CI = 3.12-3.29) for femoral shaft, and 23.32/1000 person-years (95% CI = 23.11-23.54) for hip. As compared with hip fracture residents, non-hip LE fracture residents were more likely to be immobile (58.1% vs 18.4%), to be dependent in all activities of daily living (31.6% vs 10.8%), to be transferred mechanically (20.5% vs 4.4%), to be overweight (mean body mass index = 26.6 vs 24.0 kg/m2 ), and to have diabetes (34.8% vs 25.7%). Our findings that non-hip LE fractures often occur in severely functionally impaired residents suggest these fractures may have a different mechanism of injury than hip fractures. The resident differences in our study highlight the need for distinct prevention strategies for hip and non-hip LE fractures.