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Background Hospital-acquired disability (HAD) is common and often related to low physical activity while in the hospital. Objective To examine whether wearable hospital activity trackers can be used to predict HAD. Design A prospective observational study between January 2016 and March 2017. Setting An academic medical center. Participants Community-dwelling older adults, aged 60 years or older, enrolled within 24 hours of admission to general medicine (n = 46). Main measures Primary outcome was HAD, defined as having one or more new activity of daily living deficits, decline of four or greater on the Late-Life Function and Disability Instrument (calculated between baseline and discharge), or discharge to a skilled nursing facility. Hospital activity (mean active time, mean sedentary time, and mean step counts per day) was measured using ankle-mounted accelerometers. The association of the literature-based threshold of 900 steps/day with HAD was also evaluated. Results Mean age was 73.2 years (SD = 9.5 years), 48% were male, and 76% were white. Median length of stay was 4 days (interquartile range [IQR] = 2.0-6.0 days); 61% (n = 28) reported being able to walk without assistance of another person or walking aid at baseline. Median daily activity time and step counts were 1.1 h/d (IQR = 0.7-1.7 h/d) and 1455.7 steps/day (IQR = 908.5-2643 steps/day), respectively. Those with HAD (41%; n = 19) had lower activity time (0.8 vs 1.4 h/d; P = .04) and fewer step counts (1186 vs 1808 steps/day; P = .04), but no difference in sedentary time, compared to those without HAD. The 900 steps/day threshold had poor sensitivity (40%) and high specificity (85%) for detecting HAD. Conclusions Low hospital physical activity, as measured by wearable accelerometers, is associated with HAD. Clinicians can utilize wearable technology data to refer patients to physical/occupational therapy services or other mobility interventions, like walking programs. J Am Geriatr Soc 68:261-265, 2020.

After passage of the 21st Century Cures Act, the National Institutes of Health held a workshop in 2017 to consider expanding its inclusion policy to encompass individuals of all ages. American Geriatrics Society (AGS) leaders and members participated in the workshop and formal feedback period. AGS advocacy clearly impacted the resulting workshop report and Inclusion Across the Lifespan policy that eliminates upper-age limits for research participation unless risk justified and changes the language used to describe older adults and other vulnerable groups. AGS recommendations that were not specifically stated in the updated policy were to encourage active recruitment of older adults, add standard measures of function and/or frailty, and change review criteria to ensure the health status of a study population mirrors typical clinical populations. The updated inclusion policy ultimately offers academic geriatrics programs the opportunities to expand knowledge about health in aging and to continue to provide leadership for research and advocacy efforts on behalf of older adults. J Am Geriatr Soc 67:211-217, 2019.

Objectives Little is known about how nursing home staff use resident characteristics to individualize care delivery or whether care is affected by implicit bias. Design Randomized factorial clinical vignette survey. Setting Sixteen nursing homes in North Carolina. Participants Nursing, rehabilitation, and social services staff (n = 433). Measurements Vignettes describing hypothetical residents were generated from a matrix of clinical and demographic characteristics. Resident age, race and gender were suggested by a photo. Participants completed up to four randomly assigned vignettes (n = 1615), rating the likelihood that 12 fall prevention activities would be used for the resident. Fixed and random effects mixed model analysis examined the impact of vignette resident characteristics and staff characteristics on four intervention categories. Results Staff reported a higher likelihood of fall prevention activities in all four categories for residents with a prior fall (0.2–0.5 points higher, 10 point scale, P < 0.05), but other risk factors did not affect scores. There was little evidence of individualization; only dementia increased the reported likelihood of environmental modification (0.3, P < 0.001, 95% CI 0.2–0.5). Individualization did not vary with staff licensure category or clinical experience. Registered nurses consistently reported higher likelihoods of all fall prevention activities than did licensed practical nurses, unlicensed staff and other professional staff (1.0–2.7 points, P < 0.001 to 0.005). There was a small degree of implicit racial bias; staff indicated that environmental modification would be less likely to occur in otherwise identical vignettes including a photo of a black rather than a white resident (−0.2 points, 95% CI −0.3 to −0.1). Conclusion Nursing home staff report a standardized approach to fall prevention without individualization. We found a small impact from implicit racial bias that should be further explored.

Background Nursing home (NH) residents who require assistance during mealtimes are at risk for malnutrition. Supportive handfeeding is recommended, yet there is limited evidence supporting use of a specific handfeeding technique to increase meal intake. Objectives To compare efficacy of three handfeeding techniques for assisting NH residents with dementia with meals: Direct Hand (DH), Over Hand (OH), and Under Hand (UH). Design A prospective pilot study using a within-subjects experimental Latin square design with randomization to one of three handfeeding technique sequences. Setting and Participants 30 residents living with advanced dementia in 11 U.S. NHs. Measurements Time required for assistance; meal intake (% eaten); and feeding behaviors, measured by the Edinburgh Feeding Evaluation in Dementia (EdFED) scale. Intervention Research Assistants provided feeding assistance for 18 video-recorded meals per resident (N = 540 meals). Residents were assisted with one designated technique for 6 consecutive meals, changing technique every 2 days. Results Mean time spent providing meal assistance did not differ significantly between techniques. Mean meal intake was greater for DH (67 ± 15.2%) and UH (65 ± 15.0%) with both significantly greater than OH (60 ± 15.1%). Feeding behaviors were more frequent with OH (8.3 ± 1.8%), relative to DH (8.0 ± 1.8) and UH (7.7 ± 1.8). Conclusion All three techniques are time neutral. UH and DH are viable options to increase meal intake among NH residents with advanced dementia and reduce feeding behaviors relative to OH feeding.

This report summarizes the presentations and recommendations of the eleventh annual American Geriatrics Society and National Institute on Aging research conference, "Osteoporosis and Soft Tissue (Muscle/Fat) Disorders," on March 11-12, 2019, in Bethesda, Maryland. Falls, fractures, and sarcopenia have a major impact on health in older adults, and they are interconnected by known risk factors. The link between osteoporosis, which is common in older adults, and the risk of falls is well known. Sarcopenia, the age-related decline in skeletal muscle mass and function, is also associated with an increased risk of falls and fractures because it reduces strength and leads to functional limitations. In addition to increasing the risk of falls, sarcopenia and osteoporosis can lead to frailty, reduced quality of life, morbidity, and mortality. The conference highlighted the impact of bone and soft tissue disorders on quality of life, morbidity, and mortality in older adults. Presenters described factors that contribute to these disorders; health disparities experienced by various subpopulations; and promising biological, pharmacologic, and behavioral interventions to prevent or treat these disorders. The workshop identified many research gaps and questions along with research recommendations that have the potential to enhance the prospect of healthy aging and improved quality of life for older adults. J Am Geriatr Soc 68:31-38, 2019.

Older adults with advanced chronic kidney disease (CKD) experience functional impairment that can complicate CKD management. Failure to recognize functional impairment may put these individuals at risk of further functional decline, nursing home placement, and missed opportunities for timely goals-of-care conversations. Routine geriatric assessment could be a useful tool for identifying older adults with CKD who are at risk of functional decline and provide contextual information to guide clinical decision-making. Two innovative programs were implemented in the Veterans Health Administration that incorporate geriatric assessment into a nephrology visit. In one program, a geriatrician embedded in a nephrology clinic used standardized geriatric assessment tools with individuals with CKD aged 70 and older (Comprehensive Geriatric Assessment for CKD) (CGA-4-CKD). In the second program, a nephrology clinic used comprehensive appointments for individuals aged 75 and older to conduct geriatric assessments and CKD care (Renal Silver). Data on 68 veterans who had geriatric assessments through these programs between November 2013 and May 2015 are reported. In CGA-4-CKD, difficulty with one or more activities of daily living (ADLs), history of falls, and cognitive impairment were each found in 27.3% of participants. ADL difficulty was found in 65.7%, falls in 28.6%, and cognitive impairment in 51.6% of participants in Renal Silver. Geriatric assessment guided care processes in 45.4% (n = 15) of veterans in the CGA-4-CKD program and 37.1% (n = 13) of those in Renal Silver. Findings suggest there is a significant burden of functional impairment in older adults with CKD. Knowledge of this impairment is applicable to CKD management.

BACKGROUND/OBJECTIVES: To examine whether chronic kidney disease (CKD) at all stages is associated with fracture risk after adjusting for competing mortality, and determine whether age or race modifies the relationship between CKD and fracture risk. DESIGN: Prospective cohort study. SETTING: Department of Veterans Affairs (VA) national healthcare system. PARTICIPANTS: Men receiving VA primary care aged ≥ 65 years with no history of fracture or osteoporosis therapy (n=712, 918). MEASUREMENTS: We determined CKD stage from baseline estimated glomerular filtration rate (eGFR) values. Participants were followed up to 10 years for occurrence of any fracture or death. We ascertained fractures and covariates from VA medical records and Medicare claims. RESULTS: Of the 356,459 older Veterans with CKD (defined as eGFR < 60ml/min/1.73m(2)), 15.7% (n=56,032) experienced a fracture and 43.0% (n=153,438) died over a median time at risk of 5.2 years. Compared to veterans without CKD, those with CKD Stages 3-5 had an elevated risk of death, which biased estimates from traditional survival models. Competing risk models showed that Stage 3 CKD was associated with increased hazard [adjusted subdistribution hazard ratio (sdHR), 1.07, 95% CI 1.02-1.11] of fracture (compared to those without CKD), and a trend towards increased hazards for Stage 4 (sdHR,1.07, 95% CI 0.94-1.22) and Stage 5 (sdHR,1.31, 95% CI 0.97-1.77) CKD. Age, race, and bone mineral density did not modify the relationship between CKD and fracture risk. CONCLUSIONS: Among older male Veterans, CKD, including stage 3, is associated with a moderately increased fracture risk irrespective of age, race, or bone mineral density.

OBJECTIVES: To determine whether an intervention that improves nursing home (NH) staff connections, communication, and problem solving (CONNECT) would improve implementation of a falls reduction education program (FALLS). DESIGN: Cluster randomized trial. SETTING: Community (n = 4) and Veterans Affairs (VA) NHs (n = 4). PARTICIPANTS: Staff in any role with resident contact (n = 497). INTERVENTION: NHs received FALLS alone (control) or CONNECT followed by FALLS (intervention), each delivered over 3 months. CONNECT used storytelling, relationship mapping, mentoring, self-monitoring, and feedback to help staff identify communication gaps and practice interaction strategies. FALLS included group training, modules, teleconferences, academic detailing, and audit and feedback. MEASUREMENTS: NH staff completed surveys about interactions at baseline, 3 months (immediately after CONNECT or control period), and 6 months (immediately after FALLS). A random sample of resident charts was abstracted for fall risk reduction documentation (n = 651). Change in facility fall rates was an exploratory outcome. Focus groups were conducted to explore changes in organizational learning. RESULTS: Significant improvements in staff perceptions of communication quality, participation in decision-making, safety climate, caregiving quality, and use of local interaction strategies were observed in intervention community NHs (treatment-by-time effect P = .01) but not in VA NHs, where a ceiling effect was observed. Fall risk reduction documentation did not change significantly, and the direction of change in individual facilities did not relate to observed direction of change in fall rates. Fall rates did not change in control facilities (falls/bed per year: baseline, 2.61; after intervention, 2.64) but decreased by 12% in intervention facilities (falls/bed per year: baseline, 2.34; after intervention, 2.06); the effect of treatment on rate of change was 0.81 (95% confidence interval = 0.55-1.20). CONCLUSION: CONNECT has the potential to improve care delivery in NHs, but the trend toward improving fall rates requires confirmation in a larger ongoing study. Language: en

To compare the cost-effectiveness of population screening for vitamin D insufficiency with that of universal vitamin D supplementation in community-dwelling older adults.A Markov decision model simulating follow-up over a 36-month period. Published data were used to estimate values for the model, including costs (measured in 2011 U.S. dollars), utilities (measured in quality-adjusted life years (QALYs)), and probabilities.Decision analysis simulation from a societal perspective.Hypothetical cohort of community-dwelling women and men aged 65 to 80.Net monetary benefit (NMB) was calculated by subtracting the incremental cost of the strategy from the product of incremental QALYs and willingness-to-pay threshold. A higher NMB indicates greater cost-effectiveness.In women aged 65 to 80, population screening was slightly more cost-effective than universal supplementation, with an incremental NMB of $224 compared with $189 (P.001). Population screening in men was also more cost-effective than universal supplementation (incremental NMB $298 vs $260, P.001). Results differed according to age group. In those aged 65, population screening had cost-effectiveness similar to that of universal supplementation in women ($59 vs $71) and men ($114 vs $120), whereas in those aged 80, population screening was substantially more cost-effective than universal supplementation in women ($563 vs $428) and men ($703 vs $571).Population screening and universal supplementation for vitamin D insufficiency are cost-effective strategies in community-dwelling older women and men. In the oldest old, population screening may be more cost-effective than universal supplementation.

Observational studies are an important source of evidence to evaluate treatment benefits and harms in older adults, but lack of comparability in the outcome risk factors between the treatment groups leads to confounding. Propensity score (PS) analysis is widely used in aging research to reduce confounding. Understanding the assumptions and pitfalls of common PS analysis methods is fundamental to apply and interpret PS analysis. This review was developed based on a symposium of the American Geriatrics Society Annual Meeting on the use and interpretation of PS analysis in May 2014. PS analysis involves 2 steps: estimation of PS and estimation of the treatment effect using PS. Typically estimated from a logistic model, PS reflects the probability of receiving a treatment given observed characteristics possessed by an individual. PS can be viewed as a summary score that contains information on multiple confounders, and this score is used in matching, weighting, or stratification to achieve confounder balance between the treatment groups to estimate the treatment effect. Among these methods, matching and weighting generally reduce confounding more effectively than stratification. Although PS is often included as a covariate in the outcome regression model, this is no longer a best practice due to its sensitivity to modeling assumption. None of these methods reduce confounding by unmeasured variables. In this review, we explain the rationale, best practices, and caveats in conducting PS analysis using a case study that examined the effectiveness of angiotensin-converting enzyme inhibitors on mortality and hospitalization in older adults with heart failure.

Objectives: To explore the perspectives and priorities of nursing home residents, family members, and frontline nursing staff concerning a broad range of items representing common targets of culture change initiatives. Design: Qualitative study. Setting: A Veterans Affairs Community Living Center and two community nursing homes in North Carolina. Participants: Residents (n = 21), family members (n = 21), and direct-care nursing staff (n = 21) were recruited, with equal numbers in each group from each site. Measurements: Participants rated the importance of 62 items from the Centers for Medicare and Medicaid Services Artifacts of Culture Change instrument. Participants sorted cards reflecting each culture change artifact in two phases, identifying and ranking those of more and less importance to them to derive one distribution of preferences for each respondent. Q-sort analysis identified groups of respondents who prioritized similar items; qualitative analysis sought themes or explanations for the responses. Results: Wide variation in respondent preferences was observed. Some respondents viewed several items that others valued highly as unimportant or undesirable. Some items were not high priorities for any respondents. Four groups of respondents with similar preferences were identified: practical and independence-focused respondents, who prioritized ease of use of the physical environment; staff-focused respondents, who prioritized nursing staff retention and development; consistency and choice-focused respondents, who prioritized stable nurse staff-resident relationships and resident choice; and activity and community-focused respondents, who prioritized community gathering spaces and activities. Conclusion: Resident, family, and staff priorities for culture change vary, and diverse priorities of stakeholders should be considered to inform culture change efforts on a local and national level.

OBJECTIVES: To assess the efficacy of once-yearly zoledronic acid (ZOL) 5 mg in increasing bone mineral density (BMD) in men with a recent hip fracture participating in the Health Outcomes and Reduced Incidence with Zoledronic Acid Once-Yearly Recurrent Fracture Trial and to compare the efficacy with that in women from the same study. DESIGN: Randomized, placebo-controlled, double-blind trial. SETTING: International multicenter. PARTICIPANTS: Five hundred and eight men and 1,619 women within 90 days of surgical repair of low-trauma hip fracture in the same study (for comparison). INTERVENTION: Once-yearly intravenous (IV) ZOL 5 mg (n = 248) or placebo (n = 260), loading dose of vitamin D, daily calcium, and vitamin D supplements. MEASUREMENT: Changes in BMD. RESULTS: Percentage change from baseline in total hip BMD at Months 12 and 24 was significantly higher with ZOL than with placebo (between-group difference, 2.0%, P = .003, and 3.8%, P = .002, respectively). Percentage change from baseline in femoral neck BMD at Month 24 was significantly higher with ZOL than with placebo (3.8%, P = .003). The BMD benefit was comparable with that observed in women in this study. New clinical fractures occurred in 36 (7.1%) participants (ZOL, n = 16; placebo, n = 20; P = .64). The ZOL safety profile was comparable with that of placebo, with no significant differences in cardiovascular or long-term renal function and a trend toward lower mortality in ZOL-treated men. CONCLUSION: Once-yearly IV ZOL 5 mg increases bone mass at the hip and femoral neck in men within 90 days of repair of a low-trauma hip fracture. Increases were of a similar magnitude to those observed in women in the same study.

OBJECTIVES: To evaluate the cost-effectiveness of oral bisphosphonate therapy for osteoporosis in women at different ages and life expectancies. DESIGN: A Markov model was used to analyze oral bisphosphonate treatment for 5 years compared to no intervention. Women at each age were divided into life expectancy quartiles: the lowest 1% to 25% (sickest group), the two middle 26% to 75% (average health group), and the highest 76% to 100% of life expectancy (healthiest group). Simulations were performed for hypothetical cohorts at 5-year intervals with starting ages between 50 and 90 and for each life expectancy group and followed for up to 100 years or until death. Data sources included published fracture rates, costs, utility values, and mortality risks. SETTING: Computer simulation using a societal perspective. PARTICIPANTS: Hypothetical cohort of women with various life expectancies beginning osteoporosis treatment between the age of 50 and 90 years. MEASUREMENTS: Cost per quality-adjusted life years (QALY) gained for 5 years of bisphosphonate therapy compared to no treatment. Cost-effectiveness was defined at a willingness-to-pay of $50,000. RESULTS: In the healthiest group, all costs were less than $18,000 per QALY. In the median quartiles of life expectancy, lifetime costs per QALY were less than $27,000 for patients at all ages; treatment became cost-saving at a starting age of 75 and remained so through a starting age of 85. Even in the sickest group, although osteoporosis treatment was not cost-saving, it remained cost-effective through a starting age of 90 with lifetime costs of less than $43,000 per QALY. CONCLUSION: Treatment with an oral bisphosphonate for 5 years was cost-effective for all women, regardless of quartile of life expectancy. Advanced age should not prevent consideration of osteoporosis treatment based on cost effectiveness, and strategies to improve care, such as nurse-led screening programs or electronic medical record tools, are needed.

Osteoporosis is common in elderly postmenopausal women and is associated with a high incidence of fractures. The incidence of osteoporotic fractures is reported to increase with age,1 and more than 50% of all fragility fractures in the community arise in women aged 75 and older.2 Vertebral and hip fractures are highly prevalent in older adults2,3 and contribute to significant morbidity and mortality in this age group.4–9 The incidence of vertebral fractures in women increases strongly with age, ranging from 7.8 per 1,000 person-years at age 55 to 65 to 19.6 per 1,000 person-years at age 75 and older.10 Moreover, patients with previous fractures have higher risk of future fractures11,12 as they lose significant bone and muscle mass.13 Hip fracture is a strong risk factor for subsequent nonhip skeletal fractures in the elderly population. It is not only a marker of prevalent osteoporosis but also a precipitant of functional and bone density decline, which further increases fall and fracture risk.14 Several studies have shown a significant relationship between increasing age and decreasing likelihood of receiving effective osteoporosis treatment.14–18 Thus, untreated osteoporosis leads to an increase in hospitalization and medical expenditure.19 This therapeutic challenge is mainly attributed to two issues. First, elderly patients have been underrepresented in osteoporosis clinical trials, and the efficacy and safety of the available drugs for this population remains unclear.20 Second, the complex and frequent administration requirements of oral bisphosphonates makes it more challenging in patients with cognitive or functional impairments and in those who take multiple oral medications. Consequently, the compliance with oral bisphosphonates is low, and therefore, this disease remains undertreated.21–24 A once-yearly intravenous infusion of zoledronic acid (ZOL) 5 mg is a more-attractive therapeutic option in the management of osteoporosis than daily, weekly, or even monthly regimens of oral bisphosphonates.25 Moreover, the use of intravenous ZOL 5 mg in preventing bone loss and reducing the risk of fractures is well established in post-menopausal osteoporosis.25–28 ZOL is the first intravenous therapeutic agent with documented protection against vertebral and nonvertebral fractures, including hip fracture,25–28 but the efficacy and safety of intravenous bisphosphonates in postmenopausal women aged 75 and older is not well established. Given the high prevalence of osteoporosis, the under-use of antiresorptive treatment, and the paucity of efficacy and safety data regarding bisphosphonate therapy for osteoporosis in elderly postmenopausal women, a post hoc analysis was conducted to determine the efficacy and safety of once-yearly intravenous ZOL 5 mg in reducing the risk of vertebral and nonvertebral fractures in elderly post-menopausal women aged 75 and older with osteoporosis.

Objectives Computerized order entry algorithms can improve the quality of care; but are rarely used in nursing homes (NHs). We conducted a pilot study to: (1) develop order entry algorithms for 5 common NH problems, and (2) test their acceptance, use, and preliminary impact on quality indicators and resource utilization.

OBJECTIVES: To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs). DESIGN: Qualitative analysis. SETTING: Four randomly selected community nursing homes. PARTICIPANTS: NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs). MEASUREMENTS: Interviews (n=35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers' Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description. RESULTS: None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were “checklists” to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities. CONCLUSION: Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.

Objectives To examine the effect of functional impairments in older women with diabetes mellitus (DM) on incident clinical fractures. Design Secondary analysis of two large prospective cohort studies. Setting North Carolina Established Populations for Epidemiologic Studies of the Elderly (EPESE) and Women's Health Initiative (WHI) clinical trials. Participants EPESE included 2,704 community-dwelling women aged 65 and older; WHI clinical trials included 68,125 postmenopausal women. Measurements Women with DM at baseline were compared with women without in successive Cox proportional hazards models. Functional limitations were determined according to self-reported difficulties with activities of daily living (ADLs) and physical activities. Results The risk of any clinical fracture during the study period was greater in women with DM, after controlling for age, race and ethnicity, and body mass index, in the EPESE (hazard ratio (HR) = 1.36, 95% confidence interval (CI) = 1.08–1.72) and WHI (HR = 1.29, 95% CI = 1.19–1.39) cohorts. After inclusion of functional limitations, the greater risk of fracture associated with DM decreased in the EPESE (HR = 1.25, 95% CI = 0.98–1.59) and WHI (HR = 1.21, 95% CI = 1.12–1.31) cohorts. In participants with DM, difficulties with moderate physical activities, such as bending or stooping, walking several blocks, and heavy housework, were significantly associated with incident fracture (P

To The Editor: Medications are the most frequently used form of therapy employed in the care of older adults. Unfortunately, the frequent exclusion of these patients from premarketing clinical trials of new medications has limited our knowledge regarding the safety and efficacy of individual medications in our aging population.1 Moreover, the most common chronic condition that older adults experience is multimorbidity, with two of every three older adults having multiple chronic conditions. Multiple chronic conditions account for 66% of the country’s overall health expenditures and more than 95% of Medicare expenditures.2 Therefore, it is critical to understand the risks and benefits of medications in the presence of multimorbidity. Despite this, a recent study showed that of 190 clinical trials that explicitly considered multiple chronic conditions in the selection process, 94% excluded older patients – i.e., the very patients who have the most to benefit from therapy and in whom we know the least about medication safety.3 Because of this gap, the role of observational data and pharmacoepidemiogic research in older adults is critical. In this letter, we summarize key points from a Methodology Workshop of the same title presented at the 2013 American Geriatrics Society Annual Scientific Meeting.

Falls remain a major source of morbidity for nursing facility residents.1,2 Therefore, a substantial body of research has focused on fall reduction in this setting.3–10 Several randomized, controlled trials have demonstrated that multiple-risk-factor reduction can substantially reduce fall rates and prevent fractures. Risk factors addressed in these trials included environmental hazards, adaptive equipment maintenance, psychotropic drug use, physical therapy or exercise, staff education, postfall problem solving, and hip protectors. To implement the interventions, studies have provided on-site personnel and interdisciplinary consult teams.4,6,8–10 Translating these studies into effective clinical practice using existing nursing facility staff remains a challenge. The Resident Assessment Protocol for falls of the nursing home Resident Assessment Instrument was an early attempt to operationalize multiple-risk-factor reduction on a national scale, but an evaluation of falls rates before and after the introduction of the Resident Assessment Protocol in 1991 showed no change.11 Other attempts to promote multiple-risk-factor reduction in nursing facilities using pharmacy consultants and quality assurance training have had mixed results.12–14 In general, low levels of facility participation and nonsignificant changes in provider behavior have been reported. A widely used method for translating evidence from trials into clinical practice is the Quality Improvement Collaborative (QIC). Quality improvement teams from each facility participate in all-day learning sessions and teleconferences during which they meet with clinical experts, exchange ideas, and generate ‘‘enthusiasm and a shared sense of commitment.’’15–17 Between sessions, teams apply what they have learned by systematically testing small changes over time using ‘‘Plan-Do-Study-Act’’ cycles. The Institute for Healthcare Improvement has popularized the QIC method, and the U.S. Health Resources and Services Administration, the Veterans Health Administration, and the United Kingdom’s National Health Service have used it. However, recent studies have questioned the effectiveness of the QIC method and called for an improved evidence base for quality improvement initiatives.15,18 The current study reports the results of a statewide QIC focused on fall prevention in nursing facilities. The primary objective was to describe the changes in clinical practice resulting from QIC participation. As an exploratory analysis, it was desired to test whether facility fall rates were different in participating facilities than in nonparticipating facilities.

Objectives To describe the time to first acute care use (e.g., emergency department (ED) use without hospitalization or rehospitalization) for older adults discharged to home after receiving postacute care in skilled nursing facilities (SNFs); to identify predictors of first acute care use. Design Retrospective cohort study using administrative claims data. Setting SNFs providing postacute care for patients in North and South Carolina (N = 1,474). Participants A cohort of Medicare beneficiaries aged 65 and older (N = 55,980) who were hospitalized and then transferred to a SNF for postacute care and subsequently discharged home (January 1, 2010, to August 31, 2011). Measurements Medicare institutional claims data (Parts A and B) and Medicare enrollment data were used; facility-level variables were obtained from CMS Nursing Home Compare. Survival from SNF discharge to first acute care use was explored. Cox proportional hazards regression models were used to describe individual-, home care–, and nursing facility–level predictors. Results After discharge from SNF to home, 22.1% of older adults had an episode of acute care use within 30 days, including 7.2% with an ED visit without hospitalization and 14.8% with a rehospitalization; 37.5% of older adults had their first acute care use within 90 days. Male sex, dual eligibility status, higher Charlson comorbidity score, certain primary diagnoses at index hospitalization (neoplasms and respiratory disease), and care in SNFs with for-profit ownership or fewer licensed practical nurses hours per patient-day were associated with greater likelihood of acute care use. Conclusion Medicare beneficiaries have a high use of acute care services after discharge from SNFs, and several factors associated with acute care use are potentially modifiable. Findings suggest the need for interventions to support beneficiaries as they transition from SNFs to home.

To evaluate the cost-effectiveness of oral bisphosphonate therapy for osteoporosis in women at different ages and life expectancies.A Markov model was used to analyze oral bisphosphonate treatment for 5 years compared to no intervention. Women at each age were divided into life expectancy quartiles: the lowest 1% to 25% (sickest group), the two middle 26% to 75% (average health group), and the highest 76% to 100% of life expectancy (healthiest group). Simulations were performed for hypothetical cohorts at 5-year intervals with starting ages between 50 and 90 and for each life expectancy group and followed for up to 100 years or until death. Data sources included published fracture rates, costs, utility values, and mortality risks.Computer simulation using a societal perspective.Hypothetical cohort of women with various life expectancies beginning osteoporosis treatment between the age of 50 and 90 years.Cost per quality-adjusted life years (QALY) gained for 5 years of bisphosphonate therapy compared to no treatment. Cost-effectiveness was defined at a willingness-to-pay of $50,000.In the healthiest group, all costs were less than $18,000 per QALY. In the median quartiles of life expectancy, lifetime costs per QALY were less than $27,000 for patients at all ages; treatment became cost-saving at a starting age of 75 and remained so through a starting age of 85. Even in the sickest group, although osteoporosis treatment was not cost-saving, it remained cost-effective through a starting age of 90 with lifetime costs of less than $43,000 per QALY.Treatment with an oral bisphosphonate for 5 years was cost-effective for all women, regardless of quartile of life expectancy. Advanced age should not prevent consideration of osteoporosis treatment based on cost effectiveness, and strategies to improve care, such as nurse-led screening programs or electronic medical record tools, are needed.