Developing a tool to measure enactment of complex quality improvement interventions in healthcare.

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.

Healthcare aide-focused interventions to improve pain management in long-term care homes: A systematic review.

OBJECTIVES: Pain is common in long-term care residents. We examined the effectiveness of interventions involving healthcare aides that aim to manage pain for these residents. DESIGN: A systematic review which follows PRISMA reporting guidelines. SETTING AND PARTICIPANTS: We examined controlled trials and intervention studies that included long-term care residents aged ≥60 years who received interventions to reduce chronic pain. Interventions were either delivered by healthcare aides at the resident level or were directed at healthcare aides to improve their pain management practices for residents. METHODS: We searched 7 databases to identify relevant studies. After screening 400 articles, we reviewed 131 full-text articles and included them if they reported a pain management intervention and measured pain with a standardized pain scale. Data were synthesized narratively. Risk of bias was assessed using the Mixed Methods Assessment Tool. RESULTS: In total, 9 studies were examined in the narrative review. Six studies described pain interventions involving education, new pain protocols and/or new assessment tools delivered to healthcare aides. Three studies described pain interventions delivered by healthcare aides to residents, which included a new incontinence care routine, light touch massage, and a bathing intervention. CONCLUSIONS AND IMPLICATIONS: Interventions involving healthcare aides may be beneficial to pain management for long-term care residents as they have the potential to reduce residents' pain and improve both pain assessment and reporting practices. Further research is warranted on specific elements that contribute to an improvement in residents' pain and to the overall role of healthcare aides care of residents.

Management of Chronic Pain in Long-Term Care: A Systematic Review and Meta-Analysis.

OBJECTIVES: Pain, a complex subjective experience, is common in care home residents. Despite advances in pain management, optimal pain control remains a challenge. In this updated systematic review, we examined effectiveness of interventions for treating chronic pain in care home residents. DESIGN: A Cochrane-style systematic review and meta-analysis using PRISMA guidelines. SETTING AND PARTICIPANTS: Randomized and nonrandomized controlled trials and intervention studies included care home residents aged ≥60 years receiving interventions to reduce chronic pain. METHODS: Six databases were searched to identify relevant studies. After duplicate removal, articles were screened by title and abstract. Full-text articles were reviewed and included if they implemented a pain management intervention and measured pain with a standardized quantitative pain scale. Meta-analyses calculated standardized mean differences (SMDs) using random-effect models. Risk of bias was assessed using the Cochrane Risk-of-Bias Tool 2.0. RESULTS: We included 42 trials in the meta-analysis and described 13 more studies narratively. Studies included 26 nondrug alternative treatments, 8 education interventions, 7 system modifications, 3 nonanalgesic drug treatments, 2 analgesic treatments, and 9 combined interventions. Pooled results at trial completion revealed that, except for nonanalgesic drugs and health system modification interventions, all interventions were at least moderately effective in reducing pain. Analgesic treatments (SMD -0.80; 95% CI -1.47 to -0.12; P = .02) showed the greatest treatment effect, followed by nondrug alternative treatments (SMD -0.70; 95% CI -0.95 to -0.45; P < .001), combined interventions (SMD -0.37; 95% CI -0.60 to -0.13; P = .002), and education interventions (SMD -0.31; 95% CI -0.48 to -0.15; P < .001). CONCLUSIONS AND IMPLICATIONS: Our findings suggest that analgesic drugs and nondrug alternative pain management strategies are the most effective in reducing pain among care home residents. Clinicians should also consider implementing nondrug alternative therapies in care homes, rather than relying solely on analgesic drug options.

Pain Assessment for Nursing Home Residents: A Systematic Review Protocol.

BACKGROUND: The burden of pain in nursing homes is substantial; however, pain assessment for both acute and chronic conditions remains inadequate, resulting in inappropriate or inadequate treatment. Complexities in assessing resident pain have been attributed to factors (barriers and facilitators) arising at the resident, healthcare provider, and healthcare system levels. OBJECTIVES: In this systematic review protocol, we identify our research approach that will be used to critically appraise and synthesize data in order to assess barriers and facilitators to pain assessment in nursing home residents aged ≥65 years. METHODS: This is a Cochrane style systematic review protocol adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Protocols reporting standards. This review will include primary (original) qualitative literature concerning either barriers or facilitators to pain assessment in older adult nursing home residents. A thematic analysis approach will be employed in collating and summarizing included data and will be categorized into resident, healthcare provider, and system-level factors. Database searches will include Abstracts in Social Gerontology, CINAHL, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and Web of Science. DISCUSSION: The identification of barriers and facilitators to pain assessment in older adult nursing home residents may assist healthcare providers across all platforms and levels of education to improve pain assessment among nursing home residents. Improving the assessment of pain has the potential to improve quality of care and ultimately quality of life for older adult nursing home residents.

Nursing Home Length of Stay in 3 Canadian Health Regions: Temporal Trends, Jurisdictional Differences, and Associated Factors.

OBJECTIVES: To assess (1) temporal changes (2008-2015) in nursing home (NH) length of stay (LoS) in 3 Canadian health jurisdictions (Edmonton, Calgary, Winnipeg), (2) resident admission characteristics associated with LoS, and (3) temporal changes of admission characteristics in each of the 3 jurisdictions. DESIGN: Retrospective cohort study using data previously collected in Translating Research in Elder Care (TREC), a longitudinal program of applied health services research in Canadian NHs. SETTING AND PARTICIPANTS: 7817 residents admitted between January 2008 and December 2015 to a stable cohort of 18 NHs that have consistently participated in TREC since 2007. METHODS: LoS was defined as time between a resident's first NH admission and final discharge from the NH sector. Analyses included descriptive statistics, Kaplan Meier estimates (unadjusted LoS), and Cox proportional hazard regressions (adjusted LoS), adjusted for resident characteristics (eg, age, cognitive performance, and health instability). We also controlled for NH size and ownership. RESULTS: In jurisdictions with increasing care needs, unadjusted median LoS [95% confidence interval (CI)] decreased over time (2008 and 2009 vs 2014 and 2015 admissions); in Calgary from 1.837 (95% CI 1.618, 2.275) to 1.328 (95% CI 1.185, 1.489) years and in Edmonton from 1.927 (95% CI 1.725, 2.188) to 1.073 (95% CI 0.936, 1.248) years. In Winnipeg, care needs and LoS remained constant (2.163, 95% CI 1.867, 2.494, vs 2.459, 95% CI 2.155, 2.883, years). Resident characteristics including higher physical dependency [hazard ratio (HR) 1.205, 95% CI 1.133, 1.282], higher cognitive impairment (HR 1.112, 95% CI 1.042, 1.187), or higher health instability (HR 1.333, 95% CI 1.224, 1.452) were associated with lower LoS. Adjustment for resident characteristics reduced jurisdictional LoS differences and rendered temporal LoS differences within jurisdictions statistically nonsignificant. CONCLUSIONS/IMPLICATIONS: In jurisdictions where care needs at admission have increased since 2008, resident LoS has decreased. Jurisdictional differences in care needs and LoS indicate that health policies may affect these outcomes. Variations of resident outcomes by policy environment require additional scrutiny.

Factors Associated With Pain Assessment for Nursing Home Residents: A Systematic Review and Meta-Synthesis.

OBJECTIVES: The burden of pain in nursing home residents is substantial; unfortunately, many times it goes undiagnosed and is inadequately treated. To improve identification of pain in this population, we aimed to review and synthesize findings from qualitative studies that report primary barriers and facilitators to pain assessment in nursing home residents. DESIGN: This is a Cochrane-style systematic review and narrative synthesis of qualitative evidence adhering to PRISMA guidelines. Databases were searched from inception to June 2018, supplemented by hand searching of references. We assessed the quality of included studies using the Critical Appraisal Skills Program Quality Appraisal Checklist. SETTING AND PARTICIPANTS: We included studies conducted in nursing homes. Studies focused on nursing home residents, nursing home staff, or both. MEASURES: Extracted data were subject to thematic analyses and were collated and summarized into 3 groups: resident, health care provider, and health care system factors. RESULTS: Thirty-one studies met our inclusion criteria. Resident factors had 3 subthemes: physical or cognitive impairments, attitudes and beliefs, and social/cultural/demographic characteristics. Health care provider factors had 3 subthemes: knowledge and skills, attitudes and beliefs, and social/cultural/demographic characteristics. Health care system-level factors had 3 subthemes: interpersonal factors, resources, and policy. Key barriers to pain assessment included the presence of resident cognitive impairment, health care providers' lack of knowledge, and the breakdown of communication across organizational hierarchies. Key facilitators to pain assessment included the identification of pain-related behaviors in residents, the experience and skills of health care providers, and establishing facility-level pain assessment protocols and guidelines. CONCLUSION AND IMPLICATIONS: Findings from this review identify primary barriers and facilitators to pain assessment in nursing home residents, highlighting key considerations for stakeholders, including health care providers, and health care policy decision makers. These efforts have the potential to improve the identification of pain in residents, and may ultimately improve pain management and residents' quality of life.

Health of health care workers in Canadian nursing homes and pediatric hospitals: a cross-sectional study.

BACKGROUND: Poor health of health care workers affects quality of care, but research and health data for health care workers are scarce. Our aim was to compare physical/mental health among health care worker groups 1) within nursing homes and pediatric hospitals, 2) between the 2 settings and 3) with the physical/mental health of the Canadian population. METHODS: Using cross-sectional data collected as part of the Translating Research in Elder Care program and the Translating Research on Pain in Children program, we examined the health of health care workers. In nursing homes, 169 registered nurses, 139 licensed practical nurses, 1506 care aides, 145 allied health care providers and 69 managers were surveyed. In pediatric hospitals, 63 physicians, 747 registered nurses, 155 allied health care providers, 49 nurse educators and 22 managers were surveyed. After standardization of the data for age and sex, we applied analyses of variance and general linear models, adjusted for multiple testing. RESULTS: Nursing home workers and registered nurses in pediatric hospitals had poorer mental health than the Canadian population. Scores were lowest for registered nurses in nursing homes (mean difference -4.4 [95% confidence interval -6.6 to -2.6]). Physicians in pediatric hospitals and allied health care providers in nursing homes had better physical health than the general population. We also found important differences in physical/mental health for care provider groups within and between care settings. INTERPRETATION: Mental health is especially poor among nursing home workers, who care for a highly vulnerable and medically complex population of older adults. Strategies including optimized work environments are needed to improve the physical and mental health of health care workers to ameliorate quality of patient care.

Inhaled magnesium sulfate in the treatment of acute asthma.

BACKGROUND: Asthma exacerbations can be frequent and range in severity from mild to life-threatening. The use of magnesium sulfate (MgSO4) is one of numerous treatment options available during acute exacerbations. While the efficacy of intravenous MgSO4 has been demonstrated, the role of inhaled MgSO4 is less clear. OBJECTIVES: To determine the efficacy and safety of inhaled MgSO4 administered in acute asthma. SPECIFIC AIMS: to quantify the effects of inhaled MgSO4 I) in addition to combination treatment with inhaled ß2-agonist and ipratropium bromide; ii) in addition to inhaled ß2-agonist; and iii) in comparison to inhaled ß2-agonist. SEARCH METHODS: We identified randomised controlled trials (RCTs) from the Cochrane Airways Group register of trials and online trials registries in September 2017. We supplemented these with searches of the reference lists of published studies and by contact with trialists. SELECTION CRITERIA: RCTs including adults or children with acute asthma were eligible for inclusion in the review. We included studies if patients were treated with nebulised MgSO4 alone or in combination with ß2-agonist or ipratropium bromide or both, and were compared with the same co-intervention alone or inactive control. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial selection, data extraction and risk of bias. We made efforts to collect missing data from authors. We present results, with their 95% confidence intervals (CIs), as mean differences (MDs) or standardised mean differences (SMDs) for pulmonary function, clinical severity scores and vital signs; and risk ratios (RRs) for hospital admission. We used risk differences (RDs) to analyse adverse events because events were rare. MAIN RESULTS: Twenty-five trials (43 references) of varying methodological quality were eligible; they included 2907 randomised patients (2777 patients completed). Nine of the 25 included studies involved adults; four included adult and paediatric patients; eight studies enrolled paediatric patients; and in the remaining four studies the age of participants was not stated. The design, definitions, intervention and outcomes were different in all 25 studies; this heterogeneity made direct comparisons difficult. The quality of the evidence presented ranged from high to very low, with most outcomes graded as low or very low. This was largely due to concerns about the methodological quality of the included studies and imprecision in the pooled effect estimates. Inhaled magnesium sulfate in addition to inhaled ß2-agonist and ipratropiumWe included seven studies in this comparison. Although some individual studies reported improvement in lung function indices favouring the intervention group, results were inconsistent overall and the largest study reporting this outcome found no between-group difference at 60 minutes (MD -0.3 % predicted peak expiratory flow rate (PEFR), 95% CI -2.71% to 2.11%). Admissions to hospital at initial presentation may be reduced by the addition of inhaled magnesium sulfate (RR 0.95, 95% CI 0.91 to 1.00; participants = 1308; studies = 4; I² = 52%) but no difference was detected for re-admissions or escalation of care to ITU/HDU. Serious adverse events during admission were rare. There was no difference between groups for all adverse events during admission (RD 0.01, 95% CI -0.03 to 0.05; participants = 1197; studies = 2). Inhaled magnesium sulfate in addition to inhaled ß2-agonistWe included 13 studies in this comparison. Although some individual studies reported improvement in lung function indices favouring the intervention group, none of the pooled results showed a conclusive benefit as measured by FEV1 or PEFR. Pooled results for hospital admission showed a point estimate that favoured the combination of MgSO4 and ß2-agonist, but the confidence interval includes the possibility of admissions increasing in the intervention group (RR 0.78, 95% CI 0.52 to 1.15; participants = 375; studies = 6; I² = 0%). There were no serious adverse events reported by any of the included studies and no between-group difference for all adverse events (RD -0.01, 95% CI -0.05 to 0.03; participants = 694; studies = 5). Inhaled magnesium sulfate versus inhaled ß2-agonistWe included four studies in this comparison. The evidence for the efficacy of ß2-agonists in acute asthma is well-established and therefore this could be considered a historical comparison. Two studies reported a benefit of ß2-agonist over MgSO4 alone for PEFR and two studies reported no difference; we did not pool these results. Admissions to hospital were only reported by one small study and events were rare, leading to an uncertain result. No serious adverse events were reported in any of the studies in this comparison; one small study reported mild to moderate adverse events but the result is imprecise. AUTHORS' CONCLUSIONS: Treatment with nebulised MgSO4 may result in modest additional benefits for lung function and hospital admission when added to inhaled ß2-agonists and ipratropium bromide, but our confidence in the evidence is low and there remains substantial uncertainty. The recent large, well-designed trials have generally not demonstrated clinically important benefits. Nebulised MgSO4 does not appear to be associated with an increase in serious adverse events. Individual studies suggest that those with more severe attacks and attacks of shorter duration may experience a greater benefit but further research into subgroups is warranted.Despite including 24 trials in this review update we were unable to pool data for all outcomes of interest and this has limited the strength of the conclusions reached. A core outcomes set for studies in acute asthma is needed. This is particularly important in paediatric studies where measuring lung function at the time of an exacerbation may not be possible. Placebo-controlled trials in patients not responding to standard maximal treatment, including inhaled ß2-agonists and ipratropium bromide and systemic steroids, may help establish if nebulised MgSO4 has a role in acute asthma. However, the accumulating evidence suggests that a substantial benefit may be unlikely.

Interventions for the Treatment of Pain in Nursing Home Residents: A Systematic Review and Meta-Analysis.

BACKGROUND: More than one-half of nursing home residents experience a complex mix of pain. Despite this, assessment and treatment of pain remain inadequate. METHODS: Using techniques of the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we assessed efficacy of interventions aimed at reducing chronic pain in nursing home residents >65 years of age. We searched for controlled trials comparing and measuring pain interventions using standardized pain scales. Two reviewers independently selected included studies, abstracted data, and assessed risk of bias. We performed meta-analyses calculating standardized mean differences (SMDs) using random effect models. RESULTS: Fourteen trials (n = 2293) were included in the meta-analysis: 7 reported nonanalgesic treatments, 4 reported analgesic treatments, 5 reported system modifications, and 2 reported educational interventions. A variety of pain scales were used, reporting outcome measures from 1 week to 1 year. Pooled results at trial completion revealed a statistically significant small treatment effect [SMD -0.33, 95% confidence interval (CI) -0.51, -0.14]. Further subgroup analysis revealed that residents receiving analgesic interventions benefited most (SMD -0.65, 95% CI -1.07, -0.23), followed by those receiving educational interventions (SMD -0.40, 95% CI -0.59, -0.21), and those receiving system modification interventions (SMD -0.26, 95% CI -0.51, -0.02). CONCLUSIONS: Nonanalgesic treatment and control groups showed no statistical differences. Our findings suggest that analgesics are the most effective pain intervention and should be considered first-line therapy. Caution should be used in interpreting findings as few trials were included, risk of bias was variable, sample sizes were small, and pooled treatment effects were small to moderate.

Making Research Results Relevant and Useable: Presenting Complex Organizational Context Data to Nonresearch Stakeholders in the Nursing Home Setting.

BACKGROUND: The success of evidence-based practice depends on clearly and effectively communicating often complex data to stakeholders. In our program of research, Translating Research in Elder Care (TREC), we focus on improving the quality and safety of care delivered to nursing home residents in western Canada. More specifically, we investigate associations among organizational context, the use of best practices and resident outcomes. Our data are complex and we have been challenged with presenting these data in a way that is not only intuitive, but also useful for our stakeholders. AIM: To illustrate a technique of organizing and presenting complex data to nonresearch stakeholders. METHODS: Using observational data previously collected within the TREC study, we used k-means cluster analysis to categorize nursing home resident care units or facilities within our sample into two distinct groups-those with more favorable contexts (work environment) and those with less favorable contexts. We then produced scatter plots to illustrate group differences between context and various quality indicators among resident care units or facilities. RESULTS: Care aides working on units with more favorable context reported higher use of best practices. When aggregated at the nursing home facility level, facilities with low rates of both urinary tract infections and indwelling catheter use are higher in organizational context. When feeding back these results to stakeholders, we identify their units so that they are able to visually assess their units, both relative to each other and relative to all other units and facilities both within and among provinces. LINKING EVIDENCE TO ACTION: Although we have not formally evaluated this method, we have used it extensively as part of the feedback we provide to stakeholders. As we are examining modifiable aspects of context, the stakeholder can then identify areas for improvement and thus implement a focused plan.

Impact of Symptoms and Care Practices on Nursing Home Residents at the End of Life: A Rating by Front-line Care Providers.

OBJECTIVES: Burdensome symptoms and potentially inappropriate care practices are common at the end of life for nursing home residents. Appropriately managing symptoms and limiting aggressive care practices is key to high-quality end-of-life care. Little research is available, however, on the opinions of nursing home care providers about the impact of symptoms and practices for both residents and care facilities. Our objectives were to (1) identify common burdensome symptoms and potentially inappropriate practices at the end of life for nursing home residents, (2) develop and assess the feasibility of a procedure to have various groups of nursing home care providers rate impact of symptoms and practices, and (3) generate recommendations for action and further research, with key policy and decision makers. DESIGN: Proof-of-concept study. Partnered research by researchers, health professionals, and decision makers to identify and explore the impact of burdensome symptoms and potentially inappropriate care practices for nursing home residents at the end of life. SETTING: Thirty-six nursing homes from Alberta, Manitoba, and Saskatchewan. PARTICIPANTS: A total of 6007 residents (prevalence rating); 4 medical directors, 5 directors of care, 4 nurse practitioners, 4 registered nurses, 5 licensed practical nurses, 5 care aides (impact rating); and 13 key policy or decision makers from Alberta, British Columbia, and Manitoba (expert panel). METHODS: Based on a literature search and data in the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0, we generated lists of burdensome symptoms and potentially inappropriate care practices for nursing home residents at the end of life. We rated prevalence of those symptoms and practices in the last quarter before death as high, medium, or low. Care providers rated the burden of symptoms and inappropriateness of practices as high, medium, or low. Directors of care rated the unnecessary cost of those symptoms and practices to a nursing home as high, medium, or low. We ranked symptoms and practices based on those ratings. We discussed our findings in an interactive expert panel and generated recommendations for action and further research. MEASUREMENTS: RAI-MDS 2.0 (symptom prevalence rating); online survey to rate symptoms and practices (impact rating). RESULTS: The 3 most prevalent symptoms were urinary incontinence (79.7%), fecal incontinence (66.7%), and responsive behaviors (63%). The 3 most prevalent practices were polypharmacy (9+ medications; 55.2%), antipsychotic use with no diagnosis of psychosis (29.2%), and physical restraint use (18.7%). The symptoms rated as having highest overall impact were pain, responsive behaviors, and urinary incontinence. Practices rated as having the most impact were polypharmacy, hospital and emergency department transitions, and antipsychotic use with no diagnosis of psychosis. CONCLUSION: Burdensome symptoms and inappropriate care practices near the end of life for residents in nursing homes are highly prevalent. Attending to those symptoms and practices is necessary to improve the quality of dying for nursing home residents. Our study provides preliminary demonstration of the feasibility and importance of engaging the spectrum of care providers in assessing the impact of symptoms and care practices on resident experience. Experiences of this proof-of-concept study will be the basis for the development of an indicator profile to monitor and improve quality of end-of-life care in nursing homes in the future.

Factors associated with rushed and missed resident care in western Canadian nursing homes: a cross-sectional survey of health care aides.

AIMS AND OBJECTIVES: To describe the nature, frequency and factors associated with care that was rushed or missed by health care aides in western Canadian nursing homes. BACKGROUND: The growing number of nursing home residents with dementia has created job strain for frontline health care providers, the majority of whom are health care aides. Due to the associated complexity of care, health care aides are challenged to complete more care tasks in less time. Rushed or missed resident care are associated with adverse resident outcomes (e.g. falls) and poorer quality of staff work life (e.g. burnout) making this an important quality of care concern. DESIGN: Cross-sectional survey of health care aides (n = 583) working in a representative sample of nursing homes (30 urban, six rural) in western Canada. METHODS: Data were collected in 2010 as part of the Translating Research in Elder Care study. We collected data on individual health care aides (demographic characteristics, job and vocational satisfaction, physical and mental health, burnout), unit level characteristics associated with organisational context, facility characteristics (location, size, owner/operator model), and the outcome variables of rushed and missed resident care. RESULTS: Most health care aides (86%) reported being rushed. Due to lack of time, 75% left at least one care task missed during their previous shift. Tasks most frequently missed were talking with residents (52% of health care aides) and assisting with mobility (51%). Health care aides working on units with higher organisational context scores were less likely to report rushed and missed care. CONCLUSION: Health care aides frequently report care that is rushed and tasks omitted due to lack of time. RELEVANCE TO CLINICAL PRACTICE: Considering the resident population in nursing homes today--many with advanced dementia and all with complex care needs--health care aides having enough time to provide physical and psychosocial care of high quality is a critical concern.

Dementia diagnosis and osteoporosis treatment propensity: a population-based nested case-control study.

AIM: Increasing age and a diagnosis of dementia both dramatically increase the risk of serious osteoporosis-related sequela. We sought to examine the factors associated with osteoporosis treatment, in relation to dementia diagnosis, in older adults with osteoporosis. METHODS: This was a population-based, retrospective, nested, case-control study utilizing administrative healthcare data from British Columbia, Canada. Community-based individuals aged ≥65 years with an osteoporosis diagnosis and continuous enrolment in the provinces' drug plan between 1991 and 2007 were eligible for inclusion. A multivariate logistic regression model was assembled to examine the relationship between dementia diagnosis, age, sex, other comorbidity, residence and osteoporosis medication dispensation. RESULTS: Almost half of the total osteoporosis cohort (n = 39 452) were dispensed an osteoporosis medication during the study period. Individuals with no dementia diagnosis were dispensed a medication significantly more often than those with a diagnosis of dementia (P < 0.001). Those patients with dementia (n = 13 315), who had been dispensed an osteoporosis drug, were more often younger, female, had not sustained a previous fracture, had ≥ 4 comorbid conditions and lived in the most central health region (P < 0.001). A diagnosis of dementia was found to be a significant negative predictor of osteoporosis drug dispensation (adjusted OR 0.55; 95% CI 0.44-0.69). Increasing comorbidity was significantly associated with receiving treatment (adjusted OR 3.30; 95% CI 2.88-3.78). CONCLUSION: Despite the wide availability of osteoporosis medications, our findings suggest that many older adults with a diagnosis of dementia, but not necessarily fewer comorbid conditions, were not receiving treatment.

Physical trauma and risk of multiple sclerosis: a systematic review and meta-analysis of observational studies.

BACKGROUND: We aimed to examine physical trauma as a risk factor for the subsequent diagnosis of MS. METHODS: We searched for observational studies that evaluated the risk for developing MS after physical trauma that occurred in childhood (≤20 years) or "premorbid" (>20 years). We performed a meta-analysis using a random effects model. RESULTS: We identified 1362 individual studies, of which 36 case-control studies and 4 cohort studies met the inclusion criteria for the review. In high quality case-control studies, there were statistically significant associations between those sustaining head trauma in childhood (OR=1.27; 95% CI, 1.12-1.44; p<0.001), premorbid head trauma (OR=1.40; 95% CI, 1.08-1.81; p=0.01), and other traumas during childhood (OR=2.31; 95% CI, 1.06-5.04; p=0.04) and the risk of being diagnosed with MS. In lesser quality studies, there was a statistical association between "other traumas" premorbid and spinal injury premorbid. No association was found between spinal injury during childhood, or fractures and burns at any age and the diagnosis of MS. The pooled OR of four cohort studies looking at premorbid head trauma was not statistically significant. CONCLUSIONS: The result of the meta-analyses of high quality case-control studies suggests a statistically significant association between premorbid head trauma and the risk for developing MS. However, cohort studies did not. Future prospective studies that define trauma based on validated instruments, and include frequency of traumas per study participant, are needed.

Practice sensitive quality indicators in RAI-MDS 2.0 nursing home data.

BACKGROUND: In recent years, improving the quality of care for nursing home residents has generated a considerable amount of attention. In response, quality indicators (QIs), based on available evidence and expert consensus, have been identified within the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS 2.0), and validated as proxy measures for quality of nursing home care. We sought to identify practice sensitive QIs; that is, those QIs believed to be the most sensitive to clinical practice. METHOD: We enlisted two experts to review a list of 35 validated QIs and to select those that they believed to be the most sensitive to practice. We then asked separate groups of practicing physicians, nurses, and policy makers to (1) rank the items on the list for overall "practice sensitivity" and then, (2) to identify the domain to which the QI was most sensitive (nursing care, physician care, or policy maker). RESULTS: After combining results of all three groups, pressure ulcers were identified as the most practice sensitive QI followed by worsening pain, physical restraint use, the use of antipsychotic medications without a diagnosis of psychosis, and indwelling catheters. When stratified by informant group, although the top five QIs stayed the same, the ranking of the 13 QIs differed by group. CONCLUSIONS: In addition to identifying a reduced and manageable set of QIs for regular reporting, we believe that focusing on these 13 practice sensitive QIs provides both the greatest potential for improving resident function and slowing the trajectory of decline that most residents experience.

Surgery and risk for multiple sclerosis: a systematic review and meta-analysis of case-control studies.

BACKGROUND: Although the precise etiology of multiple sclerosis is largely unknown, there is some speculation that a prior history of surgery may be associated with the subsequent risk for developing the disease. Therefore, we aimed to examine surgery as a risk factor for the diagnosis of multiple sclerosis. METHODS: We searched for observational studies that evaluated the risk for developing multiple sclerosis after surgery that occurred in childhood (≤ 20 years of age) or "premorbid" (> 20 years of age). We specifically included surgeries classified as: tonsillectomy, appendectomy, adenoidectomy, or "surgery". We performed a systematic review and meta-analyses and calculated odds ratios (OR) and their 95% confidence intervals (CIs) using a random effects model. RESULTS: We identified 33 case-control studies, involving 27,373 multiple sclerosis cases and 211,756 controls. There was a statistically significant association between tonsillectomy (OR = 1.32, 95% CI 1.08-1.61; 12 studies, I(2) = 44%) and appendectomy (OR = 1.16, 95% CI 1.01-1.34; 7 studies, I(2) = 0%) in individual's ≤ 20 years of age and the subsequent risk for developing multiple sclerosis. There was no statistically significant association between risk for multiple sclerosis and tonsillectomy occurring after age 20 (OR = 1.20, 95% CI 0.94-1.53; 9 studies, I(2) = 32%), in those with appendectomy at > 20 years (OR = 1.26, 95% CI 0.92-1.72; 5 studies, I(2) = 46%), and in those with adenoidectomy at ≤ 20 years of age (OR = 1.06, 95% CI 0.68-1.68; 3 studies, I(2) = 35%). The combined OR of 15 studies (N = 2,380) looking at "surgery" before multiple sclerosis diagnosis was not statistically significant (OR = 1.19, 95% CI 0.83-1.70; I(2) = 71%). CONCLUSIONS: We found a small but statistically significant and clinically important increased risk for developing multiple sclerosis, in those with tonsillectomy and appendectomy at ≤ 20 years of age. There was no convincing evidence to support the association of other surgeries and the risk for multiple sclerosis. Well-designed prospective etiological studies, pertaining to the risk for developing multiple sclerosis, ought to be conducted and should include the examination of various surgeries as risk factors.

The association between serious upper gastrointestinal bleeding and incident bisphosphonate use: a population-based nested cohort study.

BACKGROUND: Oral bisphosphonates are commonly used to prevent / treat osteoporosis. However, bisphosphonate treatment is not without risk and serious adverse effects, including upper gastrointestinal bleeding (UGIB) have been described. We sought to determine if new users of bisphosphonate drugs were more likely to suffer a serious UGIB within 120 days of drug initiation. METHODS: This was a population-based nested cohort study utilizing administrative healthcare data in British Columbia, Canada. Community based individuals ≥ 65 years with a new prescription for a bisphosphonate between 1991 and 2007 were included. A multivariate logistic regression model was used to examine the relationship between older age and the development of a serious UGIB within 120 days of new exposure to oral bisphosphonate drugs. RESULTS: Within the exposure cohort (n = 26,223), 117 individuals had suffered a serious UGIB within 120 days of incident bisphosphonate use. Cases tended to be > 80 years old, and were significantly more likely to have had a past history of gastric ulcer disease, a remote history of serious UGIB, and had been dispensed proton pump inhibitor (PPI) medications (p < 0.001 for all comparisons). After adjustment for confounding covariates, those > 80 years were more than twice as likely to suffer a UGIB when compared to those ≤ 80 years (adjusted OR = 2.03; 95% CI 1.40-2.94). A past history of serious UGIB was the strongest predictor of UGIB within 120 days of incident bisphosphonate use (adjusted OR = 2.28; 95% CI = 1.29-4.03) followed by PPI use (adjusted OR = 2.04; 95% CI = 1.35-3.07). Males were 70% more likely to suffer an UGIB compared to females (adjusted OR = 1.69; 95% CI = 1.05-2.72). CONCLUSIONS: Upper GIB is a rare, but serious, side effect of bisphosphonate therapy more often afflicting older individuals. At the same time, concern about potential rare adverse events should not discourage clinicians from prescribing bisphosphonate drugs, particularly in older patients who have already sustained a fragility fracture. Clinicians must remain cognizant of potential adverse events associated with bisphosphonate use and should routinely ask about pre-existing GI disorders and concurrent medication history prior to prescribing these drugs.

Inhaled magnesium sulfate in the treatment of acute asthma.

BACKGROUND: Asthma exacerbations can be frequent and range in severity from relatively mild to status asthmaticus. The use of magnesium sulfate (MgSO(4)) is one of numerous treatment options available during acute exacerbations. While the efficacy of intravenous MgSO(4) has been demonstrated, little is known of the role of inhaled MgSO(4). OBJECTIVES: To determine the efficacy of inhaled MgSO(4) administered in acute asthma on pulmonary functions and admission rates. SPECIFIC AIMS: To quantify the effects of inhaled MgSO(4) i) in addition to inhaled ß(2)-agonist, ii) in comparison to inhaled ß(2)-agonist alone or iii) in addition to combination treatment with inhaled ß(2) -agonist and ipratropium bromide. SEARCH METHODS: Randomised controlled trials were identified from the Cochrane Airways Group register of trials in September 2012. These trials were supplemented with trials found in the reference list of published studies, studies found using extensive electronic search techniques, as well as a review of the grey literature and conference proceedings. SELECTION CRITERIA: Randomised (or pseudo-randomised) controlled trials including adults or children with acute asthma were eligible for inclusion in the review. Studies were included if patients were treated with nebulised MgSO(4) alone or in combination with ß(2)-agonist and/or ipratropium bromide and were compared with ß(2)-agonist alone or inactive control. DATA COLLECTION AND ANALYSIS: Trial selection, data extraction and risk of bias were assessed independently by two review authors. Efforts were made to collect missing data from authors. Results are presented as standardised mean differences (SMD) for pulmonary function and risk ratios (RR) for hospital admission; both are displayed with their 95% confidence intervals (CI). MAIN RESULTS: Sixteen trials (21 references) of unclear and high risk of bias were eligible and included 896 patients who were randomised (838 patients completed). Seven of the 16 included studies involved adults exclusively, three included adults and paediatric patients, four studies enrolled paediatric patients and in the remaining two studies the age of participants was not stated.The design, definitions, intervention and outcomes were different in all 16 studies; this heterogeneity made direct comparisons difficult (see additional tables 1-3).The overall risk of bias among the included studies was variable and this is reflected in the 'Summary of findings' table with most outcomes being judged as only moderate or less.Inhaled magnesium sulfate in addition to inhaled ß(2)-agonistThere was no statistically significant improvement in pulmonary function when inhaled MgSO(4) and ß(2)-agonist was compared with ß(2)-agonist alone (SMD 0.23; 95% CI -0.27 to 0.74; three studies, n = 188); however, there was considerable between study heterogeneity. There was no clear advantage in terms of hospital admissions (RR 0.76 95% CI 0.49, 1.16; four studies, n = 249), and there were no serious adverse events reported.Inhaled magnesium sulfate versus inhaled ß(2)-agonistThe results of pulmonary function in three studies that compared inhaled MgSO(4) versus ß(2)-agonist were too heterogeneous to combine; however, two of the studies found poorer lung function on MgSO(4). There was no significant difference in terms of hospital admissions in a single small study when MgSO(4) was compared to ß(2)-agonist (RR 0.53 95% CI 0.05, 5.31; one study, n = 33), and there were no serious adverse events reported.Inhaled magnesium sulfate in addition to inhaled ß(2)-agonist and ipratropiumA further comparison has been included in the 2012 update of this review of MgSO(4) given in addition to inhaled ipratropium and ß(2)-agonist therapy (as recommended by the GINA guidelines). However, there is not yet enough data for this outcome to come to any definite conclusions, but both small studies in adults with severe asthma exacerbation found improvements in pulmonary function with additional inhaled MgSO(4). AUTHORS' CONCLUSIONS: There is currently no good evidence that inhaled MgSO(4) can be used as a substitute for inhaled ß(2)-agonists. When used in addition to inhaled ß(2)-agonists (with or without inhaled ipratropium), there is currently no overall clear evidence of improved pulmonary function or reduced hospital admissions. However, individual study results from three trials suggest possible improved pulmonary function in those with severe asthma exacerbations (FEV1 less than 50% predicted). Heterogeneity among trials included in this review precludes a more definitive conclusion. Further studies should focus on inhaled MgSO(4) in addition to the current guideline treatment for acute asthma (inhaled ß(2) -agonist and ipratropium bromide). As the evidence suggests that the most effective role of nebulised MgSO(4) may be in those with severe acute features and this is where future research should be focused. A set of core outcomes needs to be agreed upon both in adult and paediatric studies to allow improved study comparison in future.