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Objectives: This study examined the association between care unit work environments in long-term care (LTC) homes and trends in care aides' job satisfaction and burnout (exhaustion, cynicism, reduced professional efficacy) from 2014 to early 2020., Design: This was a retrospective longitudinal study using data from care aide surveys collected by the Translating Research in Elder Care research program over 3 periods: September 2014-May 2015 (T 1 ), May 2017-December 2017 (T 2 ), and September 2019-March 2020 (T 3 )., Settings and Participants: The study included 631 care aides from a stratified random sample of 84 LTC homes in 3 Canadian provinces, who participated in data collection at all 3 time points., Methods: We used mixed-effects linear regression with a "time by work environment" interaction to assess whether work environment is associated with trends in job satisfaction (Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale) and burnout (Maslach Burnout Inventory-General Survey). We standardized the outcomes using z-scores., Results: Between T 1 and T 2 , care aides in care units with less favorable work environments-characterized by less supportive leadership, weaker work culture, less effective team communication and feedback mechanisms, and insufficient structural resources and staffing-experienced a statistically significant decline in job satisfaction (B = -0.17, P < .01) and professional efficacy (B = -0.20, P < .01), along with an increase in exhaustion (B = 0.15, P < .05) and in cynicism (B = 0.27, P < .001). Those in more favorable work environments exhibited no statistically significant changes in these variables during the same period. Moreover, care aides in less favorable work environments continued to experience an increase in exhaustion from T 2 to T 3 (B = 0.16, P < .05)., Conclusions and Implications: A positive work environment at the care unit level mitigated the deterioration in care aides' job satisfaction and burnout over the period studied. Targeted interventions to improve work environments show promise in sustaining the resilience of the care aide workforce., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Older adults residing in residential aged care facilities (RACFs) often experience substandard transitions to emergency departments (EDs) through rationed and delayed ED care. We aimed to identify research describing interventions to improve transitions from RACFs to EDs., Research Design and Methods: In our scoping review, we included English language articles that (a) examined an intervention to improve transitions from RACF to EDs; and (b) focused on older adults (≥65 years). We employed content analysis. Dy et al.'s Care Transitions Framework was used to assess the contextualization of interventions and measurement of implementation success., Results: Interventions in 28 studies included geriatric assessment or outreach services (n = 7), standardized documentation forms (n = 6), models of care to improve transitions from RACFs to EDs (n = 6), telehealth services (n = 3), nurse-led care coordination programs (n = 2), acute-care geriatric departments (n = 2), an extended paramedicine program (n = 1), and a web-based referral system (n = 1). Many studies (n = 17) did not define what "improvement" entailed and instead assessed documentation strategies and distal outcomes (e.g., hospital admission rates, length of stay). Few authors reported how they contextualized interventions to align with care environments and/or evaluated implementation success. Few studies included clinician perspectives and no study examined resident- or family/friend caregiver-reported outcomes., Discussion and Implications: Mixed or nonsignificant results prevent us from recommending (or discouraging) any interventions. Given the complexity of these transitions and the need to create sustainable improvement strategies, future research should describe strategies used to embed innovations in care contexts and to measure both implementation and intervention success., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Home care is the preferred care option for most people who need support; yet abuse exists in these settings toward both home care workers and clients. There are no existing reviews that assess the scope of current research on abuse in home care, and tangentially related reviews are dated. For these reasons, a scoping review is warranted to map the current state of research on abuse in home care and examine current interventions in this field. Databases selected for searching were Medline and EMBASE on OVID, Scopus, and the following databases in EBSCOhost: Academic Search Complete, AgeLine, and Cumulative Index to Nursing and Allied Health Literature. Records were included if: (a) they were written in English; (b) the participants were home care workers or clients age 18 years or older; (c) they were published in journals; (d) they undertook empirical research; and (e) they were published within the last 10-year period. Following Graham et al. (2006), the 52 included articles are categorized as either knowledge inquiry or as intervention studies. We find three themes among knowledge inquiry studies: (1) prevalence and types of abuse in home care, (2) abuse in the context of living with dementia, and (3) working conditions and abuse. Analysis from the intervention studies suggest that not all organizations have specific policies and practices to prevent abuse, and no existing interventions to protect the well-being of clients were identified. Findings from this review can inform up-to-date practice and policymaking to improve the health and well-being of home care clients and workers., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background and Objectives: Significant quality problems exist in long-term care (LTC). Interventions to improve care are complex and often have limited success. Implementation remains a black box. We developed a program theory explaining how implementation of a complex intervention occurs in LTC settings-examining mechanisms of impact, effects of context on implementation, and implementation outcomes such as fidelity., Research Design and Methods: Concurrent process evaluation of Safer Care for Older Persons in residential Environments (SCOPE)-a frontline worker (care aide) led improvement trial in 31 Canadian LTC homes. Using a mixed-methods exploratory sequential design, qualitative data were analyzed using grounded theory to develop a conceptual model illustrating how teams implemented the intervention and how it produced change. Quantitative analyses (mixed-effects regression) tested aspects of the program theory., Results: Implementation fidelity was moderate. Implementation is facilitated by (a) care aide engagement with core intervention components; (b) supportive leadership (internal facilitation) to create positive team dynamics and help negotiate competing workplace priorities; (c) shifts in care aide role perceptions and power differentials. Mixed-effects model results suggest intervention acceptability, perceived intervention benefits, and leadership support predict implementation fidelity. When leadership support is high, fidelity is high regardless of intervention acceptability or perceived benefits., Discussion and Implications: Our program theory addresses important knowledge gaps regarding implementation of complex interventions in nursing homes. Results can guide scaling of complex interventions and future research., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: In many quality improvement (QI) and other complex interventions, assessing the fidelity with which participants 'enact' intervention activities (ie, implement them as intended) is underexplored. Adapting the evaluative approach used in objective structured clinical examinations, we aimed to develop and validate a practical approach to assessing fidelity enactment-the Overall Fidelity Enactment Scale for Complex Interventions (OFES-CI)., Methods: We developed the OFES-CI to evaluate enactment of the SCOPE QI intervention, which teaches nursing home teams to use plan-do-study-act (PDSA) cycles. The OFES-CI was piloted and revised early in SCOPE with good inter-rater reliability, so we proceeded with a single rater. An intraclass correlation coefficient (ICC) was used to assess inter-rater reliability. For 27 SCOPE teams, we used ICC to compare two methods for assessing fidelity enactment: (1) OFES-CI ratings provided by one of five trained experts who observed structured 6 min PDSA progress presentations made at the end of SCOPE, (2) average rating of two coders' deductive content analysis of qualitative process evaluation data collected during the final 3 months of SCOPE (our gold standard)., Results: Using Cicchetti's classification, inter-rater reliability between two coders who derived the gold standard enactment score was 'excellent' (ICC=0.93, 95% CI=0.85 to 0.97). Inter-rater reliability between the OFES-CI and the gold standard was good (ICC=0.71, 95% CI=0.46 to 0.86), after removing one team where open-text comments were discrepant with the rating. Rater feedback suggests the OFES-CI has strong face validity and positive implementation qualities (acceptability, easy to use, low training requirements)., Conclusions: The OFES-CI provides a promising novel approach for assessing fidelity enactment in QI and other complex interventions. It demonstrates good reliability against our gold standard assessment approach and addresses the practicality problem in fidelity assessment by virtue of its suitable implementation qualities. Steps for adapting the OFES-CI to other complex interventions are offered., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Older adults are at high risk of developing delirium in the emergency department (ED). Delirium associated with an ED visit is independently linked to poorer outcomes such as increased length of hospital stay and mortality. Performance measures (PMs) are needed to identify variations in the quality of delirium care to help focus improvement efforts where they are most needed. A preliminary list of 11 quality statements and 24 PMs was developed based on a synthesis of high-quality clinical practice guidelines. The purpose of this study is to gain consensus on a subset of PMs that can be used to evaluate delirium care quality for older ED patients., Methods and Analysis: This protocol for a modified e-Delphi study is informed by the Guidance on Conducting and REporting DElphi Studies. Clinical experts from across Canada and internationally will be recruited through peer referral, professional organisations and social media calls for expressions of interest. A minimum of 17 participants will be recruited. The primary survey for each round will consist of closed-ended questions with the opportunity to provide comments to justify decisions and clarify understanding. Using 9-point Likert scales, participants will rate each quality statement according to the concepts of importance and actionability, then its associated PMs according to the concept of necessity. Results will be fed back to participants in subsequent rounds. A priori stopping criteria have been defined in terms of consensus and stability. A minimum of three rounds will be undertaken to allow participants to have feedback, revise previous responses, then stabilise responses., Ethics and Dissemination: Ethical approval was provided at the University of Manitoba Health Research Ethics Board (ID HS25728 (H2022:340)). Informed consent will be obtained electronically using the Research Electronic Data Capture secure online platform. Knowledge translation and dissemination will be done through traditional (eg, conference presentations, peer-reviewed publications) and non-traditional (eg, ED Grand Rounds) strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The increased complexity of residents and increased needs for care in long-term care (LTC) have not been met with increased staffing. There remains a need to improve the quality of care for residents. Care aides, providers of the bulk of direct care, are well placed to contribute to quality improvement efforts but are often excluded from so doing. This study examined the effect of a facilitation intervention enabling care aides to lead quality improvement efforts and improve the use of evidence-informed best practices. The eventual goal was to improve both the quality of care for older residents in LTC homes and the engagement and empowerment of care aides in leading quality improvement efforts., Methods: Intervention teams participated in a year-long facilitative intervention which supported care aide-led teams to test changes in care provision to residents using a combination of networking and QI education meetings, and quality advisor and senior leader support. This was a controlled trial with random selection of intervention clinical care units matched 1:1 post hoc with control units. The primary outcome, between group change in conceptual research use (CRU), was supplemented by secondary staff- and resident-level outcome measures. A power calculation based upon pilot data effect sizes resulted in a sample size of 25 intervention sites., Results: The final sample included 32 intervention care units matched to 32 units in the control group. In an adjusted model, there was no statistically significant difference between intervention and control units for CRU or in secondary staff outcomes. Compared to baseline, resident-adjusted pain scores were statistically significantly reduced (less pain) in the intervention group (p=0.02). The level of resident dependency significantly decreased statistically for residents whose teams addressed mobility (p<0.0001) compared to baseline., Conclusions: The Safer Care for Older Persons in (residential) Environments (SCOPE) intervention resulted in a smaller change in its primary outcome than initially expected resulting in a study underpowered to detect a difference. These findings should inform sample size calculations of future studies of this nature if using similar outcome measures. This study highlights the problem with measures drawn from current LTC databases to capture change in this population. Importantly, findings from the trial's concurrent process evaluation provide important insights into interpretation of main trial data, highlight the need for such evaluations of complex trials, and suggest the need to consider more broadly what constitutes "success" in complex interventions., Trial Registration: ClinicalTrials.gov , NCT03426072, registered August 02, 2018, first participant site April, 05, 2018., (© 2023. The Author(s).)

Quality improvement (QI) projects are common in healthcare settings and often involve interdisciplinary teams working together towards a common goal. Many interventions and programmes have been introduced through research to convey QI skills and knowledge to healthcare workers, however, a few studies have attempted to differentiate between what individuals 'learn' or 'know' versus their capacity to apply their learnings in complex healthcare settings. Understanding and differentiating between delivery, receipt, and enactment of QI skills and knowledge is important because while enactment alone does not guarantee desired QI outcomes, it might be reasonably assumed that 'better enactment' is likely to lead to better outcomes. This paper describes the development, application and validation of a tool to measure enactment of core QI skills and knowledge of a complex QI intervention in a healthcare setting. Based on the Institute for Healthcare Improvement's Model for Improvement, existing QI assessment tools, literature on enactment fidelity and our research protocols, 10 indicators related to core QI skills and knowledge were determined. Definitions and assessment criteria were tested and refined in five iterative cycles. Qualitative data from four QI teams in long-term care homes were used to test and validate the tool. The final measurement tool contains 10 QI indicators and a five-point scale. Inter-rater reliability ranged from good to excellent. Usability and acceptability among raters were considered high. This measurement tool assists in identifying strengths and weaknesses of a QI team and allows for targeted feedback on core QI components. The indicators developed in our tool and the approach to tool development may be useful in other health related contexts where similar data are collected., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate changes in mental health and well-being (eg, quality of work life, health, intention to leave) among nursing home managers from a February 2020 prepandemic baseline to December 2021 in Alberta, Canada., Design: Repeated cross-sectional survey., Setting and Participants: A random sample of nursing homes (n = 35) in urban areas of Alberta was selected on 3 strata (region, size, ownership). Care managers were invited to participate if they (1) managed a unit, (2) worked there for at least 3 months, and (3) worked at least 6 shifts per month., Methods: We measured various mental health and well-being outcomes, including job satisfaction (Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale), burnout (Maslach Burnout Inventory-exhaustion, cynicism, efficacy), organizational citizenship behaviors (constructive efforts by individuals to implement changes to improve performance), mental and physical health (Short Form-8 Health Survey), burden of worry, and intention to leave. We use mixed effects regression to examine changes at the survey time points, controlling for staffing and resident acuity., Results: The final sample included 181 care managers (87 in the pre-COVID survey; 94 in the COVID survey). Response rates were 66.9% and 82.5% for the pre-COVID and COVID surveys, respectively. In the regression analysis, we found statistically significant negative changes in job satisfaction (mean difference -0.26, 95% CI -0.47 to -0.06; P = .011), cynicism (mean difference 0.43, 95% CI 0.02-0.84; P = .041), exhaustion (mean difference 0.84, 95% CI 0.41-1.27; P < .001), and SF-8 mental health (mean difference -6.49, 95% CI -9.60 to -3.39; P < .001)., Conclusions and Implications: Mental health and well-being of nursing home managers worsened during the pandemic, potentially placing them at risk for leaving their jobs and in need of improved support. These findings should be a major concern for policy makers, particularly given serious prepandemic workforce shortages. Ongoing assessment and support of this understudied group are needed., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The importance of reporting research evidence to stakeholders in ways that balance complexity and usability is well-documented. However, guidance for how to accomplish this is less clear. We describe a method of developing and visualising dimension-specific scores for organisational context (context rank method). We explore perspectives of leaders in long-term care nursing homes (NHs) on two methods for reporting organisational context data: context rank method and our traditionally presented binary method-more/less favourable context., Methods: We used a multimethod design. First, we used survey data from 4065 healthcare aides on 290 care units from 91 NHs to calculate quartiles for each of the 10 Alberta Context Tool (ACT) dimension scores, aggregated at the care unit level based on the overall sample distribution of these scores. This ordinal variable was then summed across ACT scores. Context rank scores were assessed for associations with outcomes for NH staff and for quality of care (healthcare aides' instrumental and conceptual research use, job satisfaction, rushed care, care left undone) using regression analyses. Second, we used a qualitative descriptive approach to elicit NH leaders' perspectives on whether the methods were understandable, meaningful, relevant, and useful. With 16 leaders, we conducted focus groups between December 2017 and June 2018: one in Nova Scotia, one in Prince Edward Island, and one in Ontario, Canada. Data were analysed using content analysis., Results: Composite scores generated using the context rank method had positive associations with healthcare aides' instrumental research use (p < .0067) and conceptual research use and job satisfaction (p < .0001). Associations were negative between context rank summary scores and rushed care and care left undone (p < .0001). Overall, leaders indicated that data presented by both methods had value. They liked the binary method as a starting point but appreciated the greater level of detail in the context rank method., Conclusions: We recommend careful selection of either the binary or context rank method based on purpose and audience. If a simple, high-level overview is the goal, the binary method has value. If improvement is the goal, the context rank method will give leaders more actionable details., (© 2022. The Author(s).)

Introduction: The paramedic practice environment presents unique challenges to data documentation and access, as well as linkage to other parts of the healthcare system. Variable or unknown data quality can influence the validity of research in paramedicine. A number of database quality assessment (DQA) frameworks have been developed and used to evaluate data quality in other areas of healthcare. The extent these or other DQA practices have been applied to paramedic research is not known. Accordingly, this scoping review aims to describe the range, extent and nature of DQA practices within research in paramedicine., Methods and Analysis: This scoping review will follow established methods for the conduct (Johanna Briggs Institute; Arksey and O'Malley) and reporting (Preferred Reporting Items in Systematic Reviews and Meta-Analyses extension for scoping reviews) of scoping reviews. In consultation with a professional librarian, a search strategy was developed representing the applicable population, concept and context. This strategy will be applied to MEDLINE (National Library of Medicine), Embase (Elsevier), Scopus (Elsevier) and CINAHL (EBSCO) to identify studies published from 2011 through 2021 that assess paramedic data quality as a stated goal. Studies will be included if they report quantitative results of DQA using data that relate primarily to the paramedic practice environment. Protocols, commentaries, case studies, interviews, simulations and experimental data-processing techniques will be excluded. No restrictions will be placed on language. Study selection will be performed by two reviewers, with a third available to resolve conflicts. Data will be extracted from included studies using a data-charting form piloted and iteratively revised based on studies known to be relevant. Results will be summarised in a chart of study characteristics, DQA-specific outcomes and key findings., Ethics and Dissemination: Ethical approval is not required. Results will be submitted to relevant conferences and peer-reviewed journals., Trial Registration: 10.17605/OSF.IO/Z287T., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Nursing home residents require daily support. While care aides provide most of this support they are rarely empowered to lead quality improvement (QI) initiatives. Researchers have shown that care aide-led teams can successfully participate in a QI intervention called Safer Care for Older Persons in Residential Care Environments (SCOPE). In preparation for a large-scale study, we conducted a 1-year pilot to evaluate how well coaching strategies helped teams to enact this intervention. Secondarily, we measured if improvements in team cohesion and communication, and resident quality of care, occurred., Methods: This study was conducted using a prospective single-arm study design, on 7 nursing homes in Winnipeg Manitoba belonging to the Translating Research in Elder Care research program. One QI team was selected per site, led by care aides who partnered with other front-line staff. Each team received facilitated coaching to enact SCOPE during three learning sessions, and additional support from quality advisors between these sessions. Researchers developed a rubric to evaluate how well teams enacted their interventions (i.e., created actionable aim statements, implemented interventions using plan-do-study-act cycles, and used measurement to guide decision-making). Team cohesion and communication were measured using surveys, and changes in unit-level quality indicators were measured using Resident Assessment Instrument-Minimum Data Set data., Results: Most teams successfully enacted their interventions. Five of 7 teams created adequate-to-excellent aim statements. While 6 of 7 teams successfully implemented plan-do-study-act cycles, only 2 reported spreading their change ideas to other residents and staff on their unit. Three of 7 teams explicitly stated how measurement was used to guide intervention decisions. Teams scored high in cohesion and communication at baseline, and hence improved minimally. Indicators of resident quality care improved in 4 nursing home units; teams at 3 of these sites were scored as 'excellent' in two or more enactment areas, versus 1 of the 3 remaining teams., Conclusions: Our coaching strategies helped most care aide-led teams to enact SCOPE. Coaching modifications are needed to help teams more effectively use measurement. Refinements to our evaluation rubric are also recommended., (© 2022. The Author(s).)

Background: Aging in place (AIP) is a policy strategy designed to help older adults remain in their community. While planners internationally have modified aspects of the older adult care continuum (e.g., home care, assisted living, nursing homes) to facilitate AIP, further improvements to community-based supports and services are also required. This study compared and constrasted the community-based factors (e.g., supports, services and personal strategies or characteristics) that family/friend care partners and healthcare stakeholders (i.e., planners/providers) view as most important to help older adults successfully AIP., Methods: An initial list of factors shown to influence AIP was created from the academic literature. These factors were used to develop a Delphi survey implemented separately on care partners and healthcare stakeholders. Respondents rated the importance of each factor using a 10-point Likert Scale (1 = not important; 10 = absolutely critical). Consensus in each group was defined when at least 80% of participants scored a factor ≥8 ("very important"), with an interquartile range ≤2. Respondents suggested additional factors during Delphi round one., Results: Care partners (N = 25) and healthcare stakeholders (N = 36) completed two and three Delphi rounds, respectively. These groups independently agreed that the following 3 (out of 27) factors were very important to help older adults age in place: keeping one's home safe, maintaining strong inter-personal relationships, and coordinating care across formal providers. While healthcare stakeholders did not reach consensus on other factors, care partners agreed that 7 additional factors (e.g., access to affordable housing, having mental health programs) were important for AIP., Conclusions: Compared to healthcare stakeholders, care partners felt that more and diverse community-based factors are important to support older adults to successfully AIP. Future research should replicate these findings in other jurisdictions, examine the availability and accessibility of the priority factors, and develop sustainable solutions to enhance their effectiveness., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Andrea Gruneir is currently an Academic Editor with PLOS ONE.

School-based healthy living interventions are widely promoted as strategies for preventing obesity. The peer-led Healthy Buddies™ curriculum has been shown to improve obesity-related outcomes in school-aged children. We examined whether these improvements existed among subgroups of children stratified by sex, income level and urban/rural geography. In a cluster-randomized controlled trial, elementary schools in Manitoba, Canada, were randomly allocated to Healthy Buddies™ (10 schools, 340 students) or standard curriculum (10 schools, 347 students). Healthy Buddies™ participants had 21weekly lessons on healthy eating, physical activity and self-efficacy, delivered by children age 9-12 to children age 6-8. We assessed pre- and post-intervention body mass index (BMI) z-scores, waist circumference, healthy living knowledge, dietary intake and self-efficacy among the younger children. Compared to standard curriculum (n = 154), Healthy Buddies™ participants (n = 157) experienced a greater reduction in waist circumference (-1.7 cm; 95% confidence interval [CI][-2.8, -0.5 cm]) and improved dietary intake (4.6; 95% CI [0.9, 8.3]), healthy living knowledge (5.9; 95% CI [2.3, 9.5]) and self-efficacy (5.3; 95% CI [1.0, 9.5]) scores. In subgroup analyses, effects for waist circumference (-2.0 cm; 95% CI [-3.6, -0.5]), healthy living knowledge (9.1; 95% CI [4.4, 13.8]) and self-efficacy (8.3; 95% CI [3.3, 13.3]) were significant among boys. Dietary intake (10.5; 95% CI [5.5, 15.4]), healthy living knowledge (9.8; 95% CI [4.5, 15.0]) and self-efficacy (6.7; 95% CI [0.7, 12.7]) improved among urban-dwelling but not rural-dwelling children. Healthy Buddies™ was effective for boys and children living in urban settings. Enhanced curricula may be needed to improve program effectiveness for select subgroups of school-aged children., (© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons, Ltd.)

Objective: To evaluate whether the male predominance of older people admitted to intensive care units (ICUs) is due to gender differences in the presence of spouses, partners, or children; rates of gender-specific disease; or triage decisions made by health system personnel., Data Sources and Collection: Three population-based datasets, 2004-2012, of Canadians ≥65 years: provincial health care data from Manitoba (n = 250 190) and national data of nursing home residents (n = 133 982) and community-based homecare recipients (n = 210 090)., Study Design: Retrospective observational study, using multivariable Cox proportional hazards and logistic regression., Principal Findings: Males predominated in ICU admissions: from Manitoba (hazard ratio [HR] = 1.87, 95% CI = 1.80-1.95), nursing homes (HR = 1.47, 1.35-1.60), and homecare (odds ratio = 1.14, 1.11-1.17). Adjustment for spouses, partners, and children did not attenuate this effect. The HR for gender was lower by 13.5 percent, relative, after excluding ICU care for cardiac causes. Male predominance was not present during a second ICU admission among survivors of a first ICU-containing hospitalization (HR = 1.07, 0.96-1.20)., Conclusions: In three older cohorts, the male predominance of ICU admission was not explained by gender differences in the presence of a spouse, partner, or children, or cardiac disease rates. The third finding suggests that triage bias is unlikely to be responsible for the male predominance., (© Health Research and Educational Trust.)

Background: Despite emerging frameworks for quality improvement (QI) implementation, little is known about how the implementation process works, particularly in nursing home settings. A study was conducted to describe "how"' a complex frontline worker-led QI program was implemented in nursing homes., Methods: Six focus groups were conducted in February 2017 with participants of a year-long, multicomponent, unit-level QI intervention in seven nursing homes in the Canadian province of Manitoba. Constant comparative analysis was used to examine perspectives of different groups of QI program participants-35 health care aides, health professionals, and managers., Results: Five themes important to the implementation process were identified: (1) "supportive elements of the QI program structure," (2) "navigating the workplace," (3) "negotiating relationships," (4) "developing individual skills," and (5) "observable program impact." Data on theme integration suggest that "supportive elements of the QI program structure" (Theme 1), "developing individual skills" (Theme 4), and "observable program impact" (on residents, health care aides, and leaders; Theme 5) operated as part of a reinforcing feedback loop that boosted team members' ability to navigate the workplace, negotiate relationships, and implement the QI program., Conclusion: Health care aide-led QI teams are feasible. However, a leadership paradox exists whereby worker-led QI programs also must incorporate concrete mechanisms to promote strong leadership and sponsor support to teams. The findings also point to the underexplored impact of interpersonal relationships between health care aides and professional staff on QI implementation., (Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background/objectives: Although examining point in time prevalence of pain among nursing home (NH) residents has value, there is a lack of evidence describing the actual changes (ie, trajectories) in pain that take place during their last 6 months of life. The main objective of this study is to describe the major pain trajectories experienced by NH residents during their last 6 months of life., Design: Secondary analysis of Resident Assessment Instrument-Minimum Data Set (MDS) 2.0 data captured as part of the longitudinal Translating Research in Elder Care data repository., Setting: Twenty-seven urban NHs in Western Canada., Participants: A total of 962 NH residents who died, had an MDS assessment completed within 30 days of death, and resided in a NH for at least 6 months. Pain trajectories were stratified by residents who were not severely cognitively impaired [Cognitive Performance Scale (CPS) ≤3] and those with severe impairment (CPS ≥4) at death., Measurements: MDS-Pain Scale; CPS., Results: In the 6 months before death, 60.1% of residents without severe cognitive impairment experienced consistently low pain; 34.6% reported experiencing either moderate to severe pain or significant increases in pain during this same period of time, and only 5.3% experienced any degree of pain improvement. When the trajectories were examined, most residents without severe cognitive impairment experienced no to mild pain in the time before their death (65.5%); however, we identified a group of residents who exhibited a pattern of pain that worsened or remained consistently high right until death (38.2%). Although the proportion of residents with "low/mild" pain trajectories was statistically greater among those who were severely impaired vs those without severe cognitive impairment, across both cognitive impairment groups, the general trend in pain trajectories is similar; with about 60% of residents experiencing either consistent low or mild pain in their last 6 months of life, and about 34% experiencing either substantially high or increasing pain levels., Conclusions: Although a majority of NH residents experienced consistently low or improved pain levels in their last 6 months of life, a substantial number experienced consistently high or substantially worsening pain levels during this same time period. These results highlight the need to better manage pain levels for some NH residents during this important period of time., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose of the Study: To (a) describe A Scheduled Shifts Staffing measure (ASSiST) to derive care aide worked hours per resident day (HCA WHRD) at facility and unit levels in nursing homes, (b) report reliability through comparisons to administrative staffing data; (c) report validity by examining associations between HCA WHRD, staff outcomes (job satisfaction, emotional exhaustion), and resident quality indicators (QIs) (e.g. falls, delirium, stage 2+ pressure ulcers), and (d) explore intrafacility variation in staffing intensity levels related to unit-level variation in resident and staff outcomes., Design and Methods: We used data from 40 care units in 12 Canadian nursing homes between 2007 and 2012. Descriptive statistics and tests of association and difference described relationships of two measures of staffing with resident and staff outcomes., Results: Annualized rates of HCA WHRD from both data sources compared well at the facility level (Pearson Product Correlation; R = 0.847, p < .001), and were correlated similarly to staff work life and many QIs. Using ASSiST data, we show that staffing levels can vary by up to 40% at the unit-level within nursing homes., Implications: ASSiST is easy to collect, more timely to retrieve than administrative data, has good criterion and construct validity, and reflects intrafacility variation in health care aide staffing levels., (© The Author 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Insulin therapy is lifesaving treatment for individuals with type 1 diabetes (T1D). Its initiation maybe associated with significant weight gain because of change from a catabolic to an anabolic state. Excessive weight-gain increases the risk of obesity and is associated with chronic disease., Objective: To examine if change in body mass index (BMI) among children in the 6 months after diagnosis with type 1 diabetes mellitus is associated with long-term obesity., Methods: This was a population-based retrospective study of 377 children (aged 2-18 yr) with type 1 diabetes. Measured heights and weights were used to calculate BMI z-scores based on Centers for Disease Control and Prevention (CDC) cut-points. Generalized Linear Models using BMI group, and age group at diagnosis; postdiagnosis weight change; and sex were applied to assess associations between postdiagnosis weight change and BMI z-score at transition to adult care., Results: Mean BMI z-score increased from 0.28 at diagnosis, to 0.53 at 6 months and 0.66 at transition to adult care. Change in BMI z-scores differed by initial BMI group and magnitude of postdiagnosis weight change. Younger children (<11 yr) had higher (p = 0.004) BMI z-scores at diagnosis but not at last visit (p = 0.1) than older (≥11 yr) children at diagnosis. BMI z-score at diagnosis, postdiagnosis weight change, female sex, and longer duration with TID were associated with higher BMI z-score at time of transition., Conclusions: BMI z-score at diagnosis was the strongest predictor of BMI z-score at time of transition to adult care, however; its effect was mediated by magnitude of weight change 6 months after diagnosis, sex, and age group at diagnosis., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Ensuring that people living in nursing homes (NHs) are afforded with dignity in their daily lives is an essential and humane concern. Promoting dignity-conserving care is fundamentally important. By nature, however, this care is all-encompassing and holistic, and from current knowledge it is challenging to create explicit strategies for measuring dignity-conserving care. In practice the majority of current NH indicators of quality care are derived from information that is routinely collected on NH residents using the RAI-Minimum Data Set (MDS). In this regard, issues that are more tangible to resident dignity such as being treated with respect, compassion, and having opportunities to engage with others are not adequately captured in current NH quality of care indicators. An initial set of markers was created by conducting an integrative literature review of existing markers and indicators of dignity in the NH setting. A modified Delphi process was used to prioritize essential dignity-conserving care markers for use by NH providers, based on factors such as the importance to fostering a culture of dignity, the impact it may have on the residents, and how achievable it is in practice. Through this consensus building technique, we were able to develop a comprehensive set of markers that capture the range and diversity of important dignity-conserving care strategies for use in NHs. The final 10 markers were judged as having high face validity by experts in the field and have explicit implications for enhancing the provision of daily dignified care to NH residents. These markers make an important addition to the traditional quality indicators used in the NH setting and as such, bridge an important gap in addressing the psychosocial and the less easily quantified needs of NH residents.

Purpose: This study investigates the increased risk of mental health outcomes and health care utilization associated with burn with two year of follow-up using a longitudinal population-based matched cohort design., Methods: Adult burn survivors (n=157) were identified from a provincial burn registry and matched 1:5 with non-burn control subjects from the general population (matching variables age and gender). The prevalence of mental health outcomes and the rates of health care utilization between the groups were compared for the 2years pre and post index date using anonymously linked population-based administrative health care data. Rates were adjusted for age, gender and sociodemographic characteristics., Results: While the burn cohort had an increased prevalence of mental health problems after burn compared to the control cohort, the burn group also had an increased prevalence of pre-burn depression (16.6% vs 7.8%; p=0.0005) and substance use disorders (8.9% vs 3.2%; p=0.001) when compared to controls. Once the pre-existing prevalence of mental illness was taken into account there was no significant change in the prevalence of mental health problems when comparing the burn group to controls over time., Conclusions: Although burns may not increase rates of mental health issues and health care utilization, burn survivors are a vulnerable group who already demonstrate increased rates of psychopathology and need for care. The present study highlights the importance of assessment and treatment of mental health outcomes in this population., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

This retrospective analysis of clinical data for children (2-18 years old) with incident T1D found surprisingly low (9%) prevalence of underweight, and high (15% overweight; 8% obesity) respectively at diagnosis. These results suggests a need to rethink the classic clinical teaching surrounding skinnier presentation at diagnosis, and importantly, the corresponding expectation of weight gain after insulin therapy initiation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

This paper examines the tension between macro level regulation and the rule breaking and rule following that happens at the workplace level. Using a comparative study of Canada, Norway, and Germany, the paper documents how long-term residential care work is regulated and organized differently depending on country, regional, and organizational contexts. We ask where each jurisdiction's staffing regulations fall on a prescription-interpretation continuum; we define prescription as a regulatory tendency to identify what to do and when and how to do it, and interpretation as a tendency to delineate what to do but not when and how to do it. In examining frontline care workers' strategies for accomplishing everyday social, health, and dining care tasks we explore how a policy-level prescriptive or interpretive regulatory approach affects the potential for promising practices to emerge on the frontlines of care work. Overall, we note the following associations: prescriptive regulatory environments tend to be accompanied by a lower ratio of professional to non-professional staff, a higher concentration of for-profit providers, a lower ratio of staff to residents and a sharper division of labour. Interpretive regulatory environments tend to have higher numbers of professionals relative to non-professionals, more limited for-profit provision, a higher ratio of staff to residents, and a more relational division of labour that enables the work to be more fluid and responsive. The implication of a prescriptive environment, such as is found in Ontario, Canada, is that frontline care workers possess less autonomy to be creative in meeting residents' needs, a tendency towards more task-oriented care and less job autonomy. The paper reveals that what matters is the type of regulation as well as the regulatory tendency towards controlling frontline care workers decision-making and decision-latitude.

Limited research exists examining long-term mental and physical health outcomes in adult survivors of pediatric burns. The authors examine the postinjury lifetime prevalence of common mental and physical disorders in a large pediatric burn cohort and compare the results with matched controls. Seven hundred and forty five survivors of childhood burns identified in the Burn Registry (<18 years old and total BSA >1% between April 1, 1988 and March 31, 2010) were matched 1:5 to the general population based on age at time of injury (index date), sex, and geographic residence. Postinjury rate ratio (RR) was used to compare burn cases and control cohorts for common mental and physical illnesses through physician billings, and hospital claims. RR was adjusted for sex, rural residence, and income. Compared with matched controls, postburn cases had significantly higher RR of all mental disorders, which remained significant (P < .05) after adjustment (major depression RR = 1.5 [confidence limit {CL}: 1.2-1.8], anxiety disorder RR = 1.5 [CL: 1.3-1.8), substance abuse RR = 2.3 [CL: 1.7-3.2], suicide attempt RR = 4.3 [CL: 1.6-12.1], or any mental disorder RR = 1.5 [CL: 1.3-1.8]). The relative rate of some physical illnesses was also significantly increased in burn survivors: arthritis RR = 1.2 (CL: 1.1-1.4), fractures RR = 1.4 (CL: 1.2-1.6), total respiratory morbidity RR = 1.1 (CL: 1.02-1.3), and any physical illness RR = 1.2 (CL: 1.1-1.3). Adult survivors of childhood burn injury have significantly increased rates of postburn mental and physical illnesses. Screening and appropriate management of these illnesses is essential when caring for this population.

Pediatric burn injuries are common, and the stress of caring for them can affect caregivers' health. This study's objective was to examine the rates of common mental and physical disorders of parents of burn-injured children (cases) compared with matched controls (controls). This is a population-based study linking the Regional Pediatric burn registry with administrative health information. Pediatric burn cases were matched 1:5 with control children from the general population based on age, sex, and geographical location then parents identified. One thousand and twenty-six parental cases and 4858 controls were identified. International Classification of Disease codes were used to identify diagnoses of common mental and physical disorders. Using rates of disease 2 years before and 2 years after the date of burn, the changes in the relative rates of health outcomes were compared between the cases and the controls. The cases had higher rates of postinjury mental and physical illness compared with the matches. However, it was found that controls also had increased rates postindex date and additionally cases had increased rates of preinjury illnesses. There was no difference in the relative rates of illnesses between the groups from pre- to post-index date. The higher rate of illness in cases postinjury could be explained by preinjury illness, and similar rate increases in the control cohort. Evaluation of the effect of a child's burn injury on parents should take into context the preexisting health of the parent. Socioeconomic factors associated with increased risk of burns may also be associated with adverse health outcomes.

Objective: The purpose of this study is to assess whether atypical antipsychotic drug (AAD) use is associated with increased risk of falling among older (≥65 years) nursing home (NH) residents., Methods: We conducted a nested case-control study using Resident Assessment Instrument Minimum Data Set 2.0 (RAI-MDS(©)) for NHs to identify falls, and population-based administrative healthcare databases to measure drug use and other study covariates. Cases (n = 626) were NH residents in Winnipeg, Canada, who had a fall between 1 April 2005 and 31 March 2007, and were matched to four controls on age, sex, and length of NH stay (n = 2388)., Results: While the odds of falling were statistically greater for AAD users versus nonusers (OR = 1.6, 95% CI 1.1-2.3), this association was type and dose dependent. Compared to nonusers, the odds of falling were greater for high-dose (>150 mg/day) quetiapine users and for high-dose (>2 mg/day) risperidone users. On the other hand, olanzapine (regardless of dose), low-dose quetiapine, and low-dose risperidone use were not associated with increased fall risk. Furthermore, the effect of AAD use, in general, on the risk of falling was significantly greater for people with wandering problems (OR = 1.8, 95% CI 1.1-3.1)., Conclusions: Our findings suggest greater risk of falling with high-dose quetiapine use and with high-dose risperidone use among NH residents. In addition, the effect of AAD use was greater for people who frequently wander. Further research is needed to confirm these findings, and to address other important unanswered questions about the safest dose and duration of AAD use., (Copyright © 2014 John Wiley & Sons, Ltd.)

Despite Canada's increasing population of seniors and the varying long-term care (LTC) strategies that provinces have implemented, little research has focused on understanding the extent to which publicly funded residential LTC bed supply varies across provinces, or the factors influencing this variation. Our study involved an analysis in which we examined the association of three select jurisdictional characteristics with LTC bed supply: population age demographics, provincial wealth, and provincial investments in home care. No significant cross-jurisdictional "ecology" or inter-relatedness was found between the variation in LTC bed supply and any of the examined variables. Interprovincial variation in bed supply also did not statistically influence alternate level of care days specific to LTC waits, suggesting that these days were not influenced simply by differences in LTC bed supply and that other provincial-level factors were in play.

Background: Neuropathic pain (NPP) is a chronic syndrome suffered by patients with multiple sclerosis (MS), for which there is no cure. Underlying cellular mechanisms involved in its pathogenesis are multifaceted, presenting significant challenges in its management., Methods: A randomized, double-blind, placebo-controlled study involving 15 relapsing-remitting MS patients with MS-induced NPP was conducted to evaluate nabilone combined with gabapentin (GBP). Eligible patients stabilized on GBP (≥1,800 mg/day) with inadequate pain relief were recruited. Nabilone or placebo was titrated over 4 weeks (0.5 mg/week increase) followed by 5-week maintenance of 1 mg oral nabilone (placebo) twice daily. Primary outcomes included two daily patient-reported measures using a 100-mm visual analog scale (VAS), pain intensity (VASpain), and impact of pain on daily activities (VASimpact). Hierarchical regression modeling was conducted on each outcome to determine if within-person pain trajectory differed across study groups, during 63-day follow-up., Results: After adjustment for key patient-level covariates (e.g., age, sex, Expanded Disability Status Scale, duration of MS, baseline pain), a significant group × time(2) interaction term was reported for both the VASpain (P < 0.01) and VASimpact score (P < 0.01), demonstrating the adjusted rate of decrease for both outcomes was statistically greater in nabilone vs placebo study group. No significant difference in attrition rates was noted between treatments. Nabilone was well tolerated, with dizziness/drowsiness most frequently reported., Conclusion: Nabilone as an adjunctive to GBP is an effective, well-tolerated combination for MS-induced NPP. The results of this study identify a novel therapeutic combination for use in this population of patients predisposed to tolerability issues that may otherwise prevent effective pain management., (Wiley Periodicals, Inc.)

Background: Nonfatal injuries are a leading cause of morbidity and mortality. In 2008, 14,065 patients with major trauma were hospitalized across Canada. With individuals surviving trauma, the psychosocial sequelae of severe physical injury have become an important area of research. No previous studies have used a population-based sample to estimate the incidence of suicidality (suicide or suicide attempt) following physical injury. This study aimed to assess the odds ratio (OR) of suicidality among adults with major trauma compared with a matched cohort., Methods: This retrospective study included persons older than 18 years who experienced an unintentional major traumatic injury (Injury Severity Score [ISS] > 12) at a regional academic trauma center between April 1, 2001, and March 31, 2011. Individuals who had no suicide attempts in the previous 5 years were identified from the trauma registry. These individuals were matched with data from provincial administrative databases. A cohort matched in terms of age, sex, and date of indexed injury was created from the general population with five controls for each trauma case, and the rate of suicidality was compared between groups., Results: A total of 2,198 adults with major were matched to 10,990 individuals. Suicidality was increased in the trauma cohort (OR, 4.31). This increase persisted even if adjusted for anxiety/mood disorders and substance abuse (adjusted OR1, 3.65) as well as residence, physical comorbidities, income quintile and those factors in adjusted OR1 (adjusted OR2, 3.30). All ORs were significant with p < 0.05 CONCLUSION: Individuals who experience major traumatic injuries are at a greater risk for postinjury suicidality compared with those in a matched cohort., Level of Evidence: Epidemiologic study, level IV.

Objective: This one-year study investigated whether the Manitoba Provincial Health Contact program for congestive heart failure (CHF) is a cost-effective intervention relative to the standard treatment., Design: Individual patient-level, randomized clinical trial of cost-effective model using data from the Health Research Data Repository at the Manitoba Centre for Health Policy, University of Manitoba., Methods: A total of 179 patients aged 40 and over with a diagnosis of CHF levels II to IV were recruited from Winnipeg and Central Manitoba and randomized into three treatment groups: one receiving standard care, a second receiving Health Lines (HL) intervention and a third receiving Health Lines intervention plus in-house monitoring (HLM). A cost-effectiveness study was conducted in which outcomes were measured in terms of QALYs derived from the SF-36 and costs using 2005 Canadian dollars. Costs included intervention and healthcare utilization. Bootstrap-resampled incremental cost-effectiveness ratios were computed to take into account the uncertainty related to small sample size., Results: The total per-patient mean costs (including intervention cost) were not significantly different between study groups. Both interventions (HL and HLM) cost less and are more effective than standard care, with HL able to produce an additional QALY relative to HLM for $2,975. The sensitivity analysis revealed that there is an 85.8% probability that HL is cost-effective if decision-makers are willing to pay $50,000., Conclusion: Findings demonstrate that the HL intervention from the Manitoba Provincial Health Contact program for CHF is an optimal intervention strategy for CHF management compared to standard care and HLM., (Copyright © 2013 Longwoods Publishing.)

Purpose of the Study: This study evaluates a nursing home Fall Management program to see if residents' mobility increased and injurious falls decreased., Design and Methods: Administrative health care use and fall occurrence report data were analyzed from 2 rural health regions in Manitoba, Canada, from June 1, 2003 to March 31, 2008. A quasiexperimental, pre-post, comparison group design was used to compare rates of three outcomes, falls, injurious falls, and falls resulting in hospitalization, by RHA (program vs nonprogram nursing homes) and period (preprogram vs postprogram). Data collectors entered occurrence report information into spreadsheets. This was supplemented with administrative health care use data., Results: The program appears to have benefitted residents-falls trended upward, injurious falls remained stable, and hospitalized falls decreased significantly (0.036-0.021 per person-year [ppy]; p = .043). Compared with nonprogram residents in the postperiod, both groups had the same fall rate, but program residents had significantly fewer injurious falls (0.596-0.746 ppy; p = .02) and hospitalized falls (0.02-0.041 ppy; p = .023)., Implications: These results are among a small body of literature showing that Fall Management was associated with improved outcomes in program nursing homes from pre- to postperiod and compared with nonprogram nursing homes. This research provides some support for the benefits of being proactive and implementing injury prevention strategies universally and pre-emptively before a resident falls, helping to minimize injuries while keeping residents mobile and active. Larger scale research is needed to identify the true effectiveness of the Fall Management program and generalizability of results.

Serious nonfatal physical injuries and burns are common occurrences that can have substantial implications for personal, social, and occupational functioning. Such injuries are frequently associated with significant mental health issues, and compromised quality of life and well-being. The purpose of this review is to summarize the current literature on physical, psychological, and social risk factors for mental health issues post-injury and to contextualize findings using Engel's biopsychosocial framework. We distinguish between pre-injury, injury-related, and post-injury risk factors for mental health problems. Female sex, history of mental health problems or trauma, type of injury, and level of pain are among the strong risk factors for mental health problems post-injury. We highlight inconsistent findings in the literature, identify directions for future research, and explore the implications of the risk factors identified for treatment and prevention., (© 2013 Wiley Periodicals, Inc.)

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 © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: Adverse events (AEs) occur frequently in nursing homes (NHs). Although the literature identifies several AE risk factors, the effect of resident transition on AE risk is less well defined. This article is the first to describe how AE risk varies across several NH transition periods and to define the most vulnerable junctures of an NH stay., Methods: This research was conducted on the population of NH residents in Manitoba, Canada, from April 1, 1999, to March 31, 2004. AEs were captured using physician-based diagnostic claims for hip fractures, other fractures, hospitalized falls, skin ulcers, and respiratory infections. AE rates were compared across several transition periods (eg, following first NH admission from hospital versus elsewhere, after NH transfer, and preceding resident death), before and after adjustment for several resident demographic, clinical, and facility-level factors., Results: Although residents (n = 22,846) spent only 6.6% of all NH days in transition, between 15.3% (skin ulcers) and 27.8% (respiratory infections) of AEs occurred during these times. Except following NH transfers, adjusted AE rates were consistently higher during all transition versus nontransition periods. Among transition periods, adjusted hip fractures, hospitalized falls, and respiratory infections were most strongly associated with resident death. Adjusted skin ulcer and non-hip fracture rates were equally highest during "pre-death" and for new residents admitted from hospital., Conclusions: This article is the first to identify the most vulnerable times of a NH stay. For newly admitted residents, our results also show that previous exposure to a hospital environment, and not simply resident illness, at least partially contributes to increased AE risk. This and additional evidence can help clinicians and administrators to better identify periods of high risk for NH residents, and also to develop more targeted care improvement strategies. More robust and frequently obtained measures of resident illness are required to further examine these issues in more detail., (Copyright © 2011 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)

Background: Staphylococcus aureus may produce superantigens that can non-specifically activate CD4(+) cells to potentially target the myelin basic protein., Objective: This study examined the association between individuals with multiple sclerosis (MS) and colonization with S. aureus harbouring superantigens., Methods: Nasal swabs were collected from non-MS subjects and patients with MS who had not experienced a relapse in the past six months (MS stable group) and who had suffered a relapse within 30 days of study recruitment (MS exacerbation group). S. aureus was isolated from the anterior nares of participants following standard procedures and staphylococcal superantigen genes (sea, seb, and tsst-1) were detected using standard laboratory PCR techniques., Results: The study enrolled 204 patients, 80 in the non-MS and MS stable groups and 44 patients in the MS exacerbation group. Overall, 27.0% of patients were colonized with S. aureus with no significant differences identified between study groups. Amongst individuals colonized with S. aureus, the prevalence of sea was significantly greater in the MS exacerbation versus non-MS study group (p < 0.05; odds ratio 7.9; 95% confidence interval 1.2-49.5)., Conclusions: The ability to rapidly screen patients for the presence of S. aureus producing sea may serve as a useful marker of a potential MS exacerbation.

Introduction: Fatigue and cognitive deficits are common symptoms affecting patients with multiple sclerosis., Methods: The effects of interferon beta on fatigue and cognitive deficits were assessed in 50 patients with relapsing multiple sclerosis (recruited at a single center). The pre-treatment assessments were performed on visits 1 and 2 (Months 0 and 3). Patients started treatment with subcutaneous interferon beta-1a or beta-1b, or intramuscular interferon beta-1a at Month 3, with reassessment at visits 3 and 4 (6 and 12 months, respectively). Co-primary endpoints were change in fatigue (Modified Fatigue Impact Scale) and change in cognition (Brief Repeatable Battery of Neuropsychological Tests) from pre-treatment to visits 3 and 4. Follow-up data were obtained for 40 patients., Results: The pre-treatment demographic and disease characteristics did not differ between groups. Improvements in fatigue levels were reported for patients receiving subcutaneous interferon beta-1a versus patients in the intramuscular interferon beta-1a group (p = .04) and in the interferon beta-1b group (p = .09). Improvements were also reported in five out of 17 cognitive indices for all the treatment groups., Conclusion: The data suggest that interferon beta may reduce fatigue and cognitive deficits in patients with relapsing multiple sclerosis. Larger, randomized, and controlled studies are required to confirm our findings.

Unlabelled: PROBLEM ADDRESSED Family physicians are not adequately following the 2002 Osteoporosis Canada guidelines for providing optimal care to patients with osteoporosis., Objective of Program: The Canadian Quality Circle (CQC) pilot project was developed to assess the feasibility of the CQC project design and to gather information for implementing a national study of quality circles (QCs). The national study would assess whether use ofQCs could improve family physicians' adherence to the osteoporosis guidelines., Program Description: The pilot project enrolled 52 family physicians and involved 7 QCs. The project had 3 phases: training and baseline data collection, educational intervention and follow-up data collection, and sessions on implementing strategies for care., Conclusion: Findings from the pilot study showed that the CQC project was well designed and well received. Use of QCs appeared to be feasible for transferring knowledge and giving physicians an opportunity to analyze work-related problems and develop solutions to them.

Introduction: Canadian Aboriginal women are at increased risk of fracture compared with the general population., Hypothesis: There is disproportionately reduced bone density in Aboriginal women as compared to white females of similar age., Methods: A random age-stratified (25-39, 40-59 and 60-75) sample of Aboriginal women (n=258) and white women (n=181) was recruited. All subjects had calcaneus and distal forearm bone density measurements, and urban participants (n=397 [90.4%]) also had measurements of the lumbar spine, hip and total body., Results: Unadjusted measurements were similar in the two groups apart from the distal forearm which showed a significantly lower mean Z-score in the Aboriginal women (p=0.03). Aboriginal women were heavier than white women (81.0+/-18.0 kg vs. 76.0+/-18.0 kg, p=0.02). Weight was directly associated with BMD at all measurement sites (p<0.00001) and potentially confounded the assessment of ethnicity on bone mass measurements. Weight-adjusted ANCOVA models demonstrated significantly lower bone density in Aboriginal than white women for the calcaneus, distal forearm, and total body (all p<0.05), but not at the other sites. ANCOVA models (adjusted for age, height and weight) were used to explore differences in bone area and bone mineral content (BMC). There was a significant effect of ethnicity on bone area with Aboriginal women having larger adjusted mean values than white women (lumbar spine p=0.038, total hip p=0.0004, total body p=0.020). In contrast, there was no detectable effect of ethnicity on BMC (all p>0.2)., Conclusions: We identified significant site-specific differences in age-and weight-adjusted bone density for Aboriginal and white women. Larger bone area, rather than a reduction in BMC, appeared to be primarily responsible. Further work is needed to define how these differences in bone density and geometry affect indices of bone strength.

Background: Traditional non-steroidal anti-inflammatory drugs (NSAIDs) are a widely used class of therapy in the treatment of chronic pain and inflammation. The drugs are effective and can be relatively inexpensive thanks to available generic versions. Unfortunately the traditional NSAIDs are associated with gastrointestinal complications in a small proportion of patients, requiring costly co-therapy with gastro-protective agents. Recently, a new class of non-steroidal anti-inflammatory agents known as coxibs has become available, fashioned to be safer than the traditional NSAIDs but priced considerably higher than the traditional generics. To help physicians choose appropriately and cost-effectively from the expanded number of anti-inflammatory therapies, scientific bodies have issued clinical practice guidelines and third party payers have published restricted reimbursement policies. The objective of this study is to determine whether an educational intervention can prompt physicians to adjust their prescribing in accordance with these expert recommendations., Methods: This is an ongoing, randomized controlled trial. All primary care physicians in Manitoba, Canada have been randomly assigned to a control group or an intervention study group. The educational intervention being evaluated consists of an audit and feedback mechanism combined with optional participation in a Continuing Medical Education interactive workshop. The primary outcome of the study is the change, from pre-to post-intervention, in physicians' appropriate prescribing of non-steroidal anti-inflammatory therapies for patients requiring chronic treatment. Three classes of non-steroidal anti-inflammatory therapies have been identified: coxib therapy, traditional NSAID monotherapy, and traditional NSAID therapy combined with gastro-protective agents. Appropriate prescribing is defined based on international clinical practice guidelines and the provincial drug reimbursement policy in Manitoba.