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To measure changes in resident-level acute care transfer rates after the PoET Southwest Spread Project (PSSP), and to identify patient and long-term care (LTC) home characteristics associated with acute care transfers after program launch. Quasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data. Sixty publicly funded LTC homes (PSSP = 30; control = 30) in Ontario, Canada, from November 2019 to December 2021. We matched 30 PSSP homes to 30 control homes with similar characteristics and described incidence rates for resident-level acute care transfers during the 7-month post-implementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and acute care transfers during the post-implementation period. We adjusted resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent sub-cohort to measure transfer patterns during the last 2 months of life. A matched cohort of 8894 residents (PSSP = 4103; control = 4791) was captured. Incidence rates of transfers increased during the post-implementation period for both PSSP (78.8 to 80.9 transfers per 1000 person-months) and control residents (66.9 to 67.9 transfers per 1000 person-months). After adjusting for covariates of interest, PSSP exposure was associated with a reduction in acute care transfers during the post-implementation period after adjusting for covariates (incidence rate ratio, 0.73; 95% CI, 0.62–0.87; P =.0002). Older age and select health regions were associated with reduced transfers, whereas higher comorbidity status and higher COVID-19 outbreak days were associated with increases. Similar patterns persisted for transfers during the last 2 months of life. This study systematically evaluated the impact of an ethics-based health care intervention in LTC using health care utilization databases. PoET implementation is associated with reduced acute care transfer rates, especially in the last 2 months of life in LTC. [ABSTRACT FROM AUTHOR]

To evaluate the scale-up of the OPUS-AP program to improve the care of residents at long-term care (LTC) centers through the systematic implementation of resident-centered approaches to care, the application of nonpharmacologic interventions for the management of behavioral and psychological symptoms of dementia (BPSD), and the deprescribing of antipsychotics where these are not clinically indicated. Prospective, closed cohort. Residents with major neurocognitive disorder (MNCD) from 24 (phase 1) and 129 (phase 2) publicly funded LTC centers in Quebec, Canada. The primary outcome was antipsychotic deprescribing (cessation or dose reduction). Secondary outcomes included changes in benzodiazepine and antidepressant prescriptions, BPSD, and falls. Comparisons were made between assessments at baseline and after 9 months. OPUS-AP phase 2 was conducted from March to December 2019 in 329 clinical wards at 129 LTC centers. At baseline, the 10,601 included residents had a mean age of 82.9: 64.6% were of female sex, 73.7% had a diagnosis of MNCD, and 47.0% had an antipsychotic prescription. These characteristics were similar to those of the 1054 residents at the 24 LTC centers in phase 1. In phase 2, successful antipsychotic deprescribing was achieved for 77.1% of residents in whom this approach was attempted, compared to 85.5% in phase 1. Phase 1 and 2 showed statistically significant improvements in the Cohen-Mansfield Agitation Inventory score and reduced use of benzodiazepines in residents with successful antipsychotic deprescribing. These improvements were of a smaller magnitude in phase 2. Statistically significant reductions in falls were observed in phase 2. The scale-up of the OPUS-AP program from 24 to 129 LTC centers was successful and resulted in a significant reduction in antipsychotic use, as well as improvement in BPSD, and reductions in benzodiazepine use and falls in residents with successful antipsychotic deprescribing. [ABSTRACT FROM AUTHOR]

To examine changes in the prescribing of end-of-life symptom management medications in long-term care (LTC) homes during the COVID-19 pandemic. Retrospective cohort study using routinely collected health administrative data in Ontario, Canada. We included all individuals who died in LTC homes between January 1, 2017, and March 31, 2021. We separated the study into 2 periods: before COVID-19 (January 1, 2017, to March 17, 2020) and during COVID-19 (March 18, 2020, to March 31, 2021). For each LTC home, we measured the percentage of residents who died before and during COVID-19 who had a subcutaneous symptom management medication prescription in their last 14 days of life. We grouped LTC homes into quintiles based on their mean prescribing rates before COVID-19, and examined changes in prescribing during COVID-19 and COVID-19 outcomes across quintiles. We captured 75,438 LTC residents who died in Ontario's 626 LTC homes during the entire study period, with 19,522 (25.9%) dying during COVID-19. The mean prescribing rate during COVID-19 ranged from 46.9% to 79.4% between the lowest and highest prescribing quintiles. During COVID-19, the mean prescribing rate in the lowest prescribing quintile increased by 9.6% compared to before COVID-19. Compared to LTC homes in the highest prescribing quintile, homes in the lowest prescribing quintile experienced the highest proportion of COVID-19 outbreaks (73.4% vs 50.0%), the largest mean outbreak intensity (0.27 vs 0.09 cases/bed), the highest mean total days with a COVID-19 outbreak (72.7 vs 24.2 days), and the greatest proportion of decedents who were transferred and died outside of LTC (22.1% vs 8.6%). LTC homes in Ontario had wide variations in the prescribing rates of end-of-life symptom management medications before and during COVID-19. Homes in the lower prescribing quintiles had more COVID-19 cases per bed and days spent in an outbreak. [ABSTRACT FROM AUTHOR]

Assess the impact of a new pharmaceutical care model on (1) polypharmacy and (2) potentially inappropriate medication (PIM) use in long-term care facilities (LTCFs). Pragmatic quasi-experimental study with a control group. This multifaceted model enables pharmacists and nurses to increase their professional autonomy by enforcing laws designed to expand their scope of practice. It also involves a strategic reorganization of care, interdisciplinary training, and systematic medication reviews. Two LTCFs exposed to the model (409 residents) were compared to 2 control LTCFs (282 residents) in Quebec, Canada. All individuals were aged 65 years or older and residing in included LTCFs. Polypharmacy (≥10 medications) and PIM (2015 Beers criteria) were analyzed throughout 12 months between March 2017 and June 2018. Groups were compared before and after implementation using repeated measures mixed Poisson or logistic regression models, adjusting for potential confounding variables. Over 12 months, for regular medications, polypharmacy decreased from 42% to 20% (exposed group) and from 50% to 41% (control group) [difference in differences (DID): 13%, P <.001]. Mean number of PIMs also decreased from 0.79 to 0.56 (exposed group) and from 1.08 to 0.90 (control group) (DID: 0.05, P =.002). Compared with usual care, this multifaceted model reduced the probability of receiving ≥10 medications and the mean number of PIMs. Greater professional autonomy, reorganization of care, training, and medication review can optimize pharmaceutical care. As the role of pharmacists is expanding in many countries, this model shows what could be achieved with increased professional autonomy of pharmacists and nurses in LTCFs. [ABSTRACT FROM AUTHOR]

To evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels. Longitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement's Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories. Adults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study. Assessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use. Quality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis. At the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms. The Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care. [ABSTRACT FROM AUTHOR]

To describe the sociodemographic, clinical, and treatment characteristics of people who are comatose in Canadian complex continuing care (CCC) and long-term care (LTC) settings, and to make recommendations to promote comprehensive care planning for this population. Retrospective, cross-sectional analysis of population data. All residents in the Canadian provinces of Alberta, Ontario, British Columbia, Manitoba, Nova Scotia, Newfoundland, Saskatchewan, and the territory of Yukon with data available from the fiscal year 2015 (April 1, 2015, to March 31, 2016). Demographic, clinical, and treatment variables were extracted from the Resident Assessment Instrument–Minimum Data Set (MDS 2.0) and were reported using descriptive statistics. Of the LTC and CCC populations, 0.07% and 3.5% were identified as comatose, respectively. Overall, people who are comatose in both CCC or LTC settings are younger and have a longer length of stay than those who are not comatose. A higher proportion of people who are comatose experience active infections and irregular bowel elimination patterns, and those who are comatose were more likely to have a feeding tube and require oxygen therapy or suctioning than those who were not comatose. However, a lower proportion of people who were comatose had documented pain. In LTC, one-quarter of people who are comatose are expected to die within 6 months. Although the prevalence of people who are comatose in LTC and CCC settings is low, this population is complex and has significant care needs that require comprehensive assessment and care planning. [ABSTRACT FROM AUTHOR]

Objective Poor food intake is known to lead to malnutrition in long-term care homes (LTCH), yet multilevel determinants of food intake are not fully understood, hampering development of interventions that can maintain the nutritional status of residents. This study measures energy and protein intake of LTCH residents, describes prevalence of diverse covariates, and the association of covariates with food intake. Design Multisite cross-sectional study. Setting Thirty-two nursing homes from 4 provinces in Canada. Participants From a sample of 639 residents (20 randomly selected per home), 628 with complete data were included in analyses. Measurements Three days of weighed food intake (main plate, estimated beverages and side dishes, snacks) were completed to measure energy and protein intake. Health records were reviewed for diagnoses, medications, and diet prescription. Mini-Nutritional Assessment-SF was used to determine nutritional risk. Oral health and dysphagia risk were assessed with standardized protocols. The Edinburgh-Feeding Questionnaire (Ed-FED) was used to identify eating challenges; mealtime interactions with staff were assessed with the Mealtime Relational Care Checklist. Mealtime observations recorded duration of meals and assistance received. Dining environments were assessed for physical features using the Dining Environment Audit Protocol, and the Mealtime Scan was used to record mealtime experience and ambiance. Staff completed the Person Directed Care questionnaire, and managers completed a survey describing features of the home and food services. Hierarchical multivariate regression determined predictors of energy and protein intake adjusted for other covariates. Results Average age of participants was 86.3 ± 7.8 years and 69% were female. Median energy intake was 1571.9 ± 411.93 kcal and protein 58.4 ± 18.02 g/d. There was a significant interaction between being prescribed a pureed/liquidized diet and eating challenges for energy intake. Age, number of eating challenges, pureed/liquidized diet, and sometimes requiring eating assistance were negatively associated with energy and protein intake. Being male, a higher Mini-Nutritional Assessment–Short Form score, often requiring eating assistance, and being on a dementia care unit were positively associated with energy and protein intake. Energy intake alone was negatively associated with homelikeness scores but positively associated with person-centered care practices, whereas protein intake was positively associated with more dietitian time. Conclusion This is the first study to consider resident, unit, staff, and home variables that are associated with food intake. Findings indicate that interventions focused on pureed food, restorative dining, eating assistance, and person-centered care practices may support improved food intake and should be the target for further research. [ABSTRACT FROM AUTHOR]

Objectives The objective of this study was to examine variation in place of death of older people dying from dementia in countries across 4 continents. Design Study of death certificate data. Methods We included deaths of older (65 + years) people whose underlying cause of death was a dementia-related disease (ICD-10: F01, F02, F03, G30) in Belgium, the Netherlands, England, Wales, France, Italy, Spain, Czech Republic, Hungary, New Zealand, United States, Canada, Mexico and South Korea. We examined associations between place of death and sociodemographic factors, social support, and residential and health care system factors. Results Overall, 4.8% of all deaths were from a dementia-related disease, ranging from 0.4% in Mexico to 6.9% in Canada. Of those deaths, the proportion occurring in hospital varied from 1.6% in the Netherlands to 73.6% in South Korea. When controlling for potential confounders, hospital death was more likely for men, those younger than 80, and those married or living in a region with a higher availability of long-term care beds, although this could not be concluded for each country. Hospital death was least likely in the Netherlands compared with other countries. Conclusions Place of death of older people who died from a dementia-related disease differs substantially between countries, which might point to organizational differences in end-of-life care provision. Increasing the availability of long-term care beds might be important to reduce the number of hospital deaths, while focusing specialized end-of-life care services on married people or those aged 65 to 79 might be crucial for achieving home death. However, proper end-of-life care needs to be ensured in hospitals, should this be the most appropriate end-of-life care setting. [ABSTRACT FROM AUTHOR]

Objective To assess the efficacy of interventions and environmental factors on increasing fluid intake or reducing dehydration risk in older people living in long-term care facilities. Design Systematic review of intervention and observational studies. Data Sources Thirteen electronic databases were searched from inception until September 2013 in all languages. References of included papers and reviews were checked. Eligibility Criteria Intervention and observational studies investigating modifiable factors to increase fluid intake and/or reduce dehydration risk in older people (≥65 years) living in long-term care facilities who could drink orally. Review Methods Two reviewers independently screened, selected, abstracted data, and assessed risk of bias from included studies; narrative synthesis was performed. Results A total of 4328 titles and abstracts were identified, 325 full-text articles were obtained and 23 were included in the review. Nineteen intervention and 4 observational studies from 7 countries investigated factors at the resident, institutional, or policy level. Overall, the studies were at high risk of bias due to selection and attrition bias and lack of valid outcome measures of fluid intake and dehydration assessment. Reported findings from 6 of the 9 intervention studies investigating the effect of multicomponent strategies on fluid intake or dehydration described a positive effect. Components included greater choice and availability of beverages, increased staff awareness, and increased staff assistance with drinking and toileting. Implementation of the US Resident Assessment Instrument reduced dehydration prevalence from 3% to 1%, P = .01. Two smaller studies reported positive effects: one on fluid intake in 9 men with Alzheimer disease using high-contrast red cups, the other involved supplementing 13 mildly dehydrated residents with oral hydration solution over 5 days to reduce dehydration. Modifications to the dining environment, advice to residents, presentation of beverages, and mode of delivery (straw vs beaker; prethickened drinks vs those thickened at the bedside) were inconclusive. Two large observational studies with good internal validity investigated effects of ownership; in Canada, for-profit ownership was associated with increased hospital admissions for dehydration; no difference was seen in dehydration prevalence between US for-profit and not-for-profit homes, although chain facilities were associated with lower odds of dehydration. This US study did not suggest any effect of staffing levels on dehydration prevalence. Conclusions A wide range of interventions and exposures were identified, but the efficacy of many strategies remains unproven due to the high risk of bias present in many studies. Reducing dehydration prevalence in long-term care facilities is likely to require multiple strategies involving policymakers, management, and care staff, but these require further investigation using more robust study methodologies. The review protocol was registered with the International Prospective Register of Systematic Reviews ( http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012003100 ). [ABSTRACT FROM AUTHOR]

The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in 6 hospitals serving as central hubs to 54 geographically associated NHs with 9574 beds in Toronto, Canada. LTC+ provided NHs with the following: (1) virtual general internal medicine (GIM) consultations; (2) nursing navigator support; (3) rapid access to laboratory and diagnostic imaging services; and (4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%), and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%), and system navigation (12%). One hundred seventy-seven (46%, 95% CI 41%-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step toward health system integration that values the expertise within the long-term care sector. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To evaluate a booklet on comfort care in dementia from the perspective of family with relevant experience, and assess nursing home resident and family factors associated with evaluations. Design: Retrospective study. Setting: Long term care facilities in French-speaking Canada, and the Netherlands and Italy. Participants: Bereaved family (n = 138). Measurements: An 8-item scale assessed the booklet’s acceptability. Usefulness was rated on a 0 to 10 scale, and perceived usefulness referred to usefulness if family had had the booklet during the resident’s stay. Families indicated preferred ways of obtaining, and the most appropriate time to get the booklet. Results: Almost all families (94%) perceived the booklet as useful. Canadian and Dutch families evaluated the booklet’s contents and format favorably, whereas Italian families’ evaluations were less favorable. Almost all families endorsed roles for physicians or nurses and about half additionally accepted availability through own initiative, in print or through the Internet. Preference of timing was highly variable. Better acceptability, usefulness, and availability through own initiative were independently associated with non-Italian nationality, presence of more physical signs discussed in the booklet, feeling ill-prepared, and higher satisfaction with care. A preference of receiving the booklet early was more likely in Italian families, those without university education, and those involved with older residents. Conclusion: The booklet is suitable to inform Dutch and Canadian families on comfort care in dementia, but implementation in Italy requires further consideration. The booklet may be integrated in advance care planning in long term care, and made available outside long term care settings to serve families who wish to be informed early. [Copyright &y& Elsevier]

Abstract: Objectives: This study examined nursing aides'' (NAs) perspectives of specific incidents of combative behavior from nursing home residents with dementia, particularly their attributions for the behaviors. Design: This research is part of a larger mixed-method study exploring combative behavior as experienced by NAs. The data for this component were collected using a cross-sectional survey design. NAs used a prospective event-reporting log or “diary” to record consecutive incidents of combative resident behaviors. Setting: Eleven rural nursing homes located in a mid-Western Canadian province. Participants: Eighty-three full-time, part-time, and casual NAs. Measurements: NAs used the diary instrument to document details of each incident of combative behavior over a 144-hour period. Findings from the diaries were explored in subsequent focus groups (reported elsewhere). Results: The 83 NAs reported 409 incidents linked to residents with dementia, with a range of 1 to 28 incidents per aide. The frequency of incidents in the preceding month was reported as follows: none (11.1%), 1–5 times (58.7%), 6–10 times (11.1%), more than 10 times (19.0%). Most incidents occurred in residents'' rooms (65%) during personal care, with the most frequent behaviors reported as slapping, squeezing, punching or hitting, and shoving. The main perceived causes of the behavior were cognitive impairment and residents not wanting care. NAs reported they could control or modify the cause in only 3% of incidents, and they were not optimistic about preventing future combative behaviors. They continued to provide care in 89% of incidents. Conclusion: In the diaries, NAs identified resident-related factors (cognitive impairment and not wanting care) as the main causes of combative behavior, and they reported having no control over these factors. In the focus groups conducted to explore diary findings, NAs reported system-level factors, also beyond their control, which affected their practices and increased their risk of exposure to combative behavior. Taken together, the results of this research program suggest a need for a broad multifaceted strategy aimed at addressing the modifiable risk factors, which includes recognizing NAs as equal partners in a team process backed by strong organizational support and commitment. [Copyright &y& Elsevier]

COVID-19 has had devastating effects on long-term care homes across much of the world, and especially within Canada, with more than 50% of the mortality from COVID-19 in 2020 in these homes. Understanding the way in which the virus spreads within these homes is critical to preventing further outbreaks. Retrospective chart review. Long-term care home residents and staff in Ontario, Canada. We conducted a longitudinal study of a large long-term care home COVID-19 outbreak in Ontario, Canada, using electronic medical records, public health records, staff assignments, and resident room locations to spatially map the outbreak through the facility. By analyzing the outbreak longitudinally, we were able to draw 3 important conclusions: (1) 84.5% had typical COVID-19 symptoms and only 15.5% of residents had asymptomatic infection; (2) there was a high attack rate of 85.8%, which appeared to be explained by a high degree of interconnectedness within the home exacerbated by staffing shortages; and (3) clustering of infections within multibedded rooms was common. Low rates of asymptomatic infection suggest that symptom-based screening in residents remains very important for detecting outbreaks, a high degree of interconnectedness explains the high attack rate, and there is a need for improved guidance for homes with multibedded rooms on optimizing resident room movement to mitigate spread of COVID-19 in long-term care homes. [ABSTRACT FROM AUTHOR]

Inappropriate antipsychotic prescribing is a key quality indicator by which clinical outcomes might be monitored and improved in long-term care (LTC), but limited evidence exists on the most effective strategies for reducing inappropriate antipsychotic use. The objective of the study was to evaluate a multicomponent approach to reduce inappropriate prescribing of antipsychotics in LTC. A prospective, stepped-wedge study design was used to evaluate the effect of the intervention. Interdisciplinary staff at 10 Canadian LTC facilities. The intervention consisted of an educational in-service, provision of evidence-based tools to assess and monitor neuropsychiatric symptoms (NPS) in dementia, and monthly interprofessional team meetings. The primary outcome was the proportion of residents receiving an antipsychotic without a diagnosis of psychosis using a standardized antipsychotic quality indicator. The weighted mean change in inappropriate antipsychotic prescribing rate from baseline to 12-month follow-up was −4.6% [standard deviation (SD) = 2.8%, P <.0001], representing a 16.1% (SD = 17.0) relative reduction. After adjusting for site, the odds ratio for the inappropriate antipsychotic prescribing quality indicator at 12 months compared to baseline was 0.73 (95% confidence interval = 0.48-0.94; chi-square = 6.59; P =.01). There were no significant changes in related quality indicators, including falls, restraint use, or behavioral symptoms. This multicomponent intervention was effective in reducing inappropriate antipsychotic prescribing in LTC without adversely affecting other domains related to quality of care, and offers a practical means by which to improve the care of older adults with dementia in LTC. [ABSTRACT FROM AUTHOR]

We examined demographic, individual, and organizational context factors associated with nurses' job satisfaction in residential long-term care (LTC) settings. Job satisfaction has implications for staff turnover, staff health, and quality of care. A cross-sectional analysis of survey data collected in the Translating Research in Elder Care program. N = 756 nurses (registered nurses: n = 308; licensed practical nurses: n = 448) from 89 residential LTC settings in 3 Western Canadian provinces. We used a generalized estimating equation model to assess demographic, individual, and organizational context factors associated with job satisfaction. Job satisfaction was measured using the Michigan Organizational Assessment Questionnaire Job Satisfaction Scale. Demographic, individual, and organizational context factors were associated with job satisfaction among nurses in residential LTC settings. At the demographic level, hours worked in 2 weeks (B = 0.002, P =.043) was associated with job satisfaction. At the individual level, emotional exhaustion-burnout (B = −0.063, P =.02) was associated with lower job satisfaction, while higher scores on empowerment (meaning) (B = 0.140, P =.015), work engagement (vigor) (B = 0.096, P =.01), and work engagement (dedication) (B = 0.129, P =.001) were associated with higher job satisfaction. With respect to organizational context, culture (B = 0.175, P <.001), organizational slack-space (eg, perceived availability and use of adequate space; B = 0.043, P =.040), and adequate orientation (B = 0.092, P <.001) were associated with higher job satisfaction. We identified previously unexamined modifiable organizational features (organizational slack-space and adequate orientation) as factors associated with LTC nurses' job satisfaction in the Canadian context. Our findings support future efforts to improve job satisfaction through improvements in organizational space and provision of adequate workplace orientation. [ABSTRACT FROM AUTHOR]

Objectives To assess the effect of a proton pump inhibitor (PPI) deprescribing guideline on PPI usage and PPI drug costs in one long-term care home in Ontario, Canada. Design Interrupted time-series analysis to compare monthly PPI usage and average monthly PPI cost per resident 9 months before guideline implementation to 12 months after. Setting One long-term care home in Ottawa, Ontario, Canada. Participants Long-term care residents prescribed a PPI over a 21-month period (n = 335). Intervention PPI deprescribing guideline and decision support tool used during quarterly medication reviews. Measurements (1) Total number of PPI prescriptions (PPI usage) and (2) average PPI drug cost per resident. We also measured the proportion of residents whose PPI was deprescribed in the preguideline period and postguideline period. Results The deprescribing guideline was associated with a decrease in PPI usage but the association was not statistically significant (−8.7 prescriptions, 95% confidence interval [CI] −22.0 to 4.6). The PPI guideline led to a significant decrease in average monthly PPI drug cost per resident over time (0.16 CAD reduction per month; 95% CI −0.29 to −0.03). In the 9 months before intervention, 57 (27.8%) of 205 eligible residents had their PPI deprescribed, and in the 12 months after intervention 134 (50.0%) of 268 eligible residents had their PPI deprescribed (difference in proportions of 22.2%; 95% CI 13.4–30.4). Discussion/conclusion The deprescribing guideline was associated with a decline PPI usage; however, this negative association was not statistically significant. PPI usage declined in the initial 6 months after guideline implementation but began to climb back to baseline after this, which may explain the lack of a significant reduction in PPI usage. This suggests that it was difficult to maintain PPI deprescribing efforts long-term. Although implementation of a PPI deprescribing guideline may lead to an initial reduction in PPI usage, and a significant reduction in the average cost of PPI prescriptions over time, it is imperative to explore ways to sustain deprescribing guideline use. [ABSTRACT FROM AUTHOR]

Objective This study assessed individual and organizational context (work environment) factors that influence use of best practices by care aides (nursing assistants) in nursing homes. Little scientific attention has been focused on understanding best practice use in nursing homes and almost none on care aides. Setting and participants A total of 1262 care aides in 25 nursing homes in the 3 Canadian prairie provinces. Care aides are unregulated workers who provide 80% of direct care to residents in Canadian nursing homes. Method We used hierarchical linear modeling to (1) assess the amount of variance in use of best practices, as reported by care aides, that could be attributed to individual or organizational factors, and (2) identify predictors of best practices use by care aides. Results At the individual level, statistically significant predictors of instrumental use of best practices included sex, age, shift worked, job efficacy, and belief suspension. At the unit level, significant predictors were social capital, organizational slack (staffing and time), number of informal interactions, and unit type. At the facility level, ownership model and province were significant. Significant predictors of conceptual use of best practices at the individual level included English as a first language, job efficacy, belief suspension, intent to use research, adequate knowledge, and number of information sources used. At the unit level, significant predictors were evaluation (feedback mechanisms), structural resources, and organizational slack (time). At the facility level, province was significant. The R 2 was 18.3% for instrumental use of best practices and 43.4% for conceptual use. Unit level factors added a substantial amount of explained variance whereas facility level factors added relatively little explained variance. Conclusions Our study suggests that context plays an important role in care aides' use of best practices in nursing homes. Individual characteristics played a more prominent role than contextual factors in predicting conceptual use of best practices. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Nursing home (NH) residents have various needs that affect the care they require. This article describes the diverse needs that new NH residents have, emphasizing the proportion of people with milder needs in multiple areas. Methods: Research was conducted on all older adults newly admitted to not-for-profit NHs in the Winnipeg Health Region, between April 1, 2005, and March 31, 2007, provided that they were assessed using the Resident Assessment Instrument Minimum Data Set (RAI/MDS 2.0) within 30 days of admission (n = 1061). Using the Activities of Daily Living (ADL) Hierarchy scale, residents were first defined as low, intermediate, or high ADL dependent. Residents'' needs were also defined using the RAI/MDS 2.0 cognitive performance (CPS) and pain scales, by their degree of behavioral problems and visual challenges, and by their frequency of bladder and bowel incontinence. Cluster analysis was used to create subgroups of residents by their severity of clinical challenges. Results: Of our cohort, 26.8% were low ADL dependent. Although some of these residents had moderate to severe needs in another area, many (46.8% of low ADL-dependent residents; 12.5% of our entire cohort) had milder needs across all clinical domains. Conversely, about one-third of our cohort was high ADL dependent; 31.7% of these residents had moderate to severe challenges in one clinical domain, and 35.5% had moderate to severe comorbid challenges. Conclusions: Overall, 12.5% of our cohort had lower needs, demonstrating the capacity for community-based programs to offset NH demands. Also, the diversity of residents'' needs highlights the importance of having both the appropriate resources and strategies available to provide quality NH care. Future research is discussed for both low- and higher-need NH residents. [Copyright &y& Elsevier]