Validation of a Rule-Based ICD-10-CM Algorithm to Detect Fall Injuries in Medicare Data.

BACKGROUND: Diagnosis-code-based algorithms to identify fall injuries in Medicare data are useful for ascertaining outcomes in interventional and observational studies. However, these algorithms have not been validated against a fully external reference standard, in ICD-10-CM, or in Medicare Advantage (MA) data. METHODS: We linked self-reported fall injuries leading to medical attention (FIMA) from the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial (reference standard) to Medicare fee-for-service (FFS) and MA data from 2015-19. We measured the area under the receiver operating characteristic curve (AUC) based on sensitivity and specificity of a diagnosis-code-based algorithm against the reference standard for presence or absence of ≥1 FIMA within a specified window of dates, varying the window size to obtain points on the curve. We stratified results by source (FFS vs MA), trial arm (intervention vs control), and STRIDE's 10 participating health care systems. RESULTS: Both reference standard data and Medicare data were available for 4 941 (of 5 451) participants. The reference standard and algorithm identified 2 054 and 2 067 FIMA, respectively. The algorithm had 45% sensitivity (95% confidence interval [CI]: 43%-47%) and 99% specificity (95% CI: 99%-99%) to identify reference standard FIMA within the same calendar month. The AUC was 0.79 (95% CI: 0.78-0.81) and was similar by FFS or MA data source and by trial arm but showed variation among STRIDE health care systems (AUC range by health care system, 0.71 to 0.84). CONCLUSIONS: An ICD-10-CM algorithm to identify fall injuries demonstrated acceptable performance against an external reference standard, in both MA and FFS data.

Improved accuracy and efficiency of primary care fall risk screening of older adults using a machine learning approach.

BACKGROUND: While many falls are preventable, they remain a leading cause of injury and death in older adults. Primary care clinics largely rely on screening questionnaires to identify people at risk of falls. Limitations of standard fall risk screening questionnaires include suboptimal accuracy, missing data, and non-standard formats, which hinder early identification of risk and prevention of fall injury. We used machine learning methods to develop and evaluate electronic health record (EHR)-based tools to identify older adults at risk of fall-related injuries in a primary care population and compared this approach to standard fall screening questionnaires. METHODS: Using patient-level clinical data from an integrated healthcare system consisting of 16-member institutions, we conducted a case-control study to develop and evaluate prediction models for fall-related injuries in older adults. Questionnaire-derived prediction with three questions from a commonly used fall risk screening tool was evaluated. We then developed four temporal machine learning models using routinely available longitudinal EHR data to predict the future risk of fall injury. We also developed a fall injury-prevention clinical decision support (CDS) implementation prototype to link preventative interventions to patient-specific fall injury risk factors. RESULTS: Questionnaire-based risk screening achieved area under the receiver operating characteristic curve (AUC) up to 0.59 with 23% to 33% similarity for each pair of three fall injury screening questions. EHR-based machine learning risk screening showed significantly improved performance (best AUROC = 0.76), with similar prediction performance between 6-month and one-year prediction models. CONCLUSIONS: The current method of questionnaire-based fall risk screening of older adults is suboptimal with redundant items, inadequate precision, and no linkage to prevention. A machine learning fall injury prediction method can accurately predict risk with superior sensitivity while freeing up clinical time for initiating personalized fall prevention interventions. The developed algorithm and data science pipeline can impact routine primary care fall prevention practice.

Post-acute sequelae of SARS-CoV-2 (PASC) in nursing home residents: A retrospective cohort study.

BACKGROUND: Post-acute sequelae of SARS-CoV-2 (PASC) describes a syndrome of physical and cognitive decline that persists after acute symptoms of infection resolve. Few studies have explored PASC among nursing home (NH) residents. METHODS: A retrospective cohort study was conducted at two NHs in Michigan. COVID-positive patients were identified from March 21, 2020 to October 26, 2021. The comparison group were patients who lived at the same NH but who were never infected during the study period. Minimum Data Set was used to examine trajectories of functional dependence (Activity of Daily Living [ADL] composite score) and cognitive function (Brief Interview for Mental Status [BIMS]). Linear mixed-effects models were constructed to estimate short-term change in function and cognition immediately following diagnosis and over time for an additional 12 months, compared to pre-COVID and non-COVID trajectories and adjusting for sex, age, and dementia status. RESULTS: We identified 171 residents (90 COVID-19 positive, 81 non-COVID) with 719 observations for our analyses. Cohort characteristics included: 108 (63%) ≥ 80 yrs.; 121 (71%) female; 160 (94%) non-Hispanic white; median of 3 comorbidities (IQR 2-4), with no significant differences in characteristics between groups. COVID-19 infection affected the trajectory of ADL recovery for the first 9 months following infection, characterized by an immediate post-infection decrease in functional status post-infection (-0.60 points, p = 0.002) followed by improvement toward the expected functional trajectory sans infection (0.04 points per month following infection, p = 0.271). CONCLUSIONS: NH residents experienced a significant functional decline that persisted for 9 months following acute infection. Further research is needed to determine whether increased rehabilitation services after COVID-19 may help mitigate this decline.

Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

OBJECTIVE: To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs). DATA SOURCES AND STUDY SETTING: Secondary data from Medicare were used. STUDY DESIGN: Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities). DATA COLLECTION: Not applicable. PRINCIPAL FINDINGS: We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001). CONCLUSIONS: HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

Barriers to delirium screening and management during hospital admission: a qualitative analysis of inpatient nursing perspectives.

BACKGROUND: Delirium in hospitalized patients is a major public health issue, yet delirium is often unrecognized and missed during inpatient admission. The objective of this study was to identify barriers to delirium screening, identification, and management from a nursing perspective on inpatient, acute care units. METHODS: This was a pre-implementation, diagnostic evaluation study to determine current practice patterns and potential barriers to optimizing delirium care at a major university hospital. A qualitative approach was used, which included focus groups of inpatient nurses working on major medical and surgical acute care units. Focus groups were conducted until signs of thematic saturation were present, and data were analyzed via inductive thematic analysis, without predetermined theories or structures. A consensus approach was utilized for transcript coding, and final themes were generated after multiple reviews of initial themes against transcript datasets. RESULTS: Focus group sessions (n = 3) were held with 18 nurses across two major inpatient units. Nurses reported several barriers to successful delirium screening and management. Specific challenges included difficulty with using delirium screening tools, an organizational culture not conducive to delirium prevention, and competing clinical priorities. Proposed solutions were also discussed, including decision-support systems with automated pager alerts and associated delirium order sets, which may help improve delirium care coordination and standardization. CONCLUSION: At a major university hospital, nurses affirm the difficulty experienced with delirium screening and identification, particularly due to screening tool challenges, cultural barriers, and clinical workload. These impediments may serve as targets for a future implementation trial to improve delirium screening and management.

Geriatric Education on Telehealth (GET) Access: A medical student volunteer program to increase access to geriatric telehealth services at the onset of COVID-19.

The coronavirus disease 2019 pandemic placed an unprecedented demand on health systems to rapidly shift ambulatory in-person care to virtual care. Geriatric patients face more challenges with video visit access compared to younger patients due to discomfort with technology and less access to devices and internet. Medical students at the University of Michigan created an initiative to improve access to and comfort with video visits for geriatric patients. The program's goals were to (a) explore options for the delivery of personalized training to older adults, (b) create materials for volunteers to successfully navigate conversations with patients and caregivers, (c) provide patients one-to-one remote guidance while identifying and overcoming barriers-with practice sessions to increase comfort, (d) share with the larger health system, and (e) ensure program sustainability. Over a 10-week evaluation period, providers whose patients worked with our geriatric education on telehealth access volunteers had a video visit rate of 43% compared to 19.2% prior to participation in the program (adjusted odds ratio = 3.38, 95% confidence interval = 2.49, 4.59), ultimately providing a platform for geriatric patients to foster stronger connections with their providers, while increasing Michigan Medicine's overall proportion of video telehealth visits.

Prescription characteristics associated with fall-related injury risk among older adults prescribed benzodiazepines: a cohort study.

BACKGROUND: Benzodiazepines (BZD) are widely prescribed to older adults despite their association with increased fall injury. Our aim is to better characterize risk-elevating factors among those prescribed BZD. METHODS: A retrospective cohort study using a 20% sample of Medicare beneficiaries with Part D prescription drug coverage. Patients with a BZD prescription ("index") between 1 April 2016 and 31 December 2017 contributed to incident (n=379,273) and continuing (n=509,634) cohorts based on prescriptions during a 6-month pre-index baseline. Exposures were index BZD average daily dose and days prescribed; baseline BZD medication possession ratio (MPR) (for the continuing cohort); and co-prescribed central nervous system-active medications. Outcome was a treated fall-related injury within 30 days post-index BZD, examined using Cox proportional hazards adjusting for demographic and clinical covariates and the dose prescribed. RESULTS: Among incident and continuing cohorts, 0.9% and 0.7% experienced fall injury within 30 days of index. In both cohorts, injury risk was elevated immediately post-index among those prescribed the lowest quantity: e.g., for <14-day fill (ref: 14-30 days) in the incident cohort, risk was 37% higher the 10 days post-fill (adjusted hazard ratio [HR] 1.37 [95% confidence interval [CI] 1.19-1.59]). Risk was elevated immediately post-index for continuing users with low baseline BZD exposure (e.g., for MPR <0.5 [ref: MPR 0.5-1], HR during days 1-10 was 1.23 [CI 1.08-1.39]). Concurrent antipsychotics and opioids were associated with elevated injury risk in both cohorts (e.g., incident HRs 1.21 [CI 1.03-1.40] and 1.22 [CI 1.07-1.40], respectively; continuing HRs 1.23 [1.10-1.37] and 1.21 [1.11-1.33]). CONCLUSIONS: Low baseline BZD exposure and a small index prescription were associated with higher fall injury risk immediately after a BZD fill. Concurrent exposure to antipsychotics and opioids were associated with elevated short-term risk for both incident and continuing cohorts.

Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults: A Mixed Methods Study.

PURPOSE: Unlike in many community-based settings, benzodiazepine (BZD) prescribing to older veterans has decreased. We sought to identify health care system strategies associated with greater facility-level reductions in BZD prescribing to older adults. METHODS: We completed an explanatory sequential mixed methods study of health care facilities in the Veterans Health Administration (N = 140). Among veterans aged ≥75 years receiving long-term BZD treatment, we stratified facilities into relatively high and low performance on the basis of the reduction in average daily dose of prescribed BZD from October 1, 2015 to June 30, 2017. We then interviewed key facility informants (n = 21) who led local BZD reduction efforts (champions), representing 11 high-performing and 6 low-performing facilities. RESULTS: Across all facilities, the age-adjusted facility-level average daily dose in October 2015 began at 1.34 lorazepam-equivalent mg/d (SD 0.17); the average rate of decrease was -0.27 mg/d (SD 0.09) per year. All facilities interviewed, regardless of performance, used passive strategies primarily consisting of education regarding appropriate prescribing, alternatives, and identifying potential patients for discontinuation. In contrast, champions at high-performing facilities described leveraging ≥1 active strategies that included individualized recommendations, administrative barriers to prescribing, and performance measures to incentivize clinicians. CONCLUSIONS: Initiatives to reduce BZD prescribing to older adults that are primarily limited to passive strategies, such as education and patient identification, might have limited success. Clinicians might benefit from additional recommendations, support, and incentives to modify prescribing practices.

Recommendations for outcome measurement for deprescribing intervention studies.

Interpreting results from deprescribing interventions to generate actionable evidence is challenging owing to inconsistent and heterogeneous outcome definitions between studies. We sought to characterize deprescribing intervention outcomes and recommend approaches to measure outcomes for future studies. A scoping literature review focused on deprescribing interventions for polypharmacy and informed a series of expert panel discussions and recommendations. Twelve experts in deprescribing research, policy, and clinical practice interventions participating in the Measures Workgroup of the US Deprescribing Research Network sought to characterize deprescribing outcomes and recommend approaches to measure outcomes for future studies. The scoping review identified 125 papers reflecting 107 deprescribing studies. Common outcomes included medication discontinuation, medication appropriateness, and a broad range of clinical outcomes potentially resulting from medication reduction. Panel recommendations included clearly defining clinically meaningful medication outcomes (e.g., number of chronic medications, dose reductions), ensuring adequate sample size and follow-up time to capture clinical outcomes resulting from medication discontinuation (e.g., quality of life [QOL]), and selecting appropriate and feasible data sources. A new conceptual model illustrates how downstream clinical outcomes (e.g., reduction in falls) should be interpreted in the context of initial changes in medication measures (e.g., reduction in mean total medications). Areas needing further development include implementation outcomes specific to deprescribing interventions and measures of adverse drug withdrawal events. Generating evidence to guide deprescribing is essential to address patient, caregiver, and clinician concerns about the benefits and harms of medication discontinuation. This article provides recommendations and an initial conceptual framework for selecting and applying appropriate intervention outcomes to support deprescribing research.

Evaluating alternative methods of comparing antihypertensive treatment intensity.

OBJECTIVES: To change blood pressure treatment, clinicians can modify medication count or dose. However, existing studies have measured count modification, which may miss clinically important dose change in the absence of count change. This research demonstrates how dose modification captures more information about management than medication count alone. STUDY DESIGN: Retrospective cohort study. METHODS: We included patients 65 years and older with established primary care at the Veterans Health Administration (July 2011-June 2013). We captured medication count and standardized dose change over 90 to 120 days using a validated pharmacy fill algorithm. We determined frequency of dose change without count change (and vice versa), no change in either, change in same direction ("concordant"), and change in opposite direction ("discordant"). We compared change according to systolic blood pressure (SBP) and compared concordance using a minimum threshold definition of dose change of at least 50% (instead of any change) of baseline dose modification. RESULTS: Among 440,801 patients, 64.2% had dose change; 22.0%, count change; 35.6%, no change in either; 42.4%, dose change without count modification; and 0.2%, count change without dose modification. Discordance occurred in 2.1% of observations. Using the minimum threshold definition of change, 68.7% had no change in either dose or count. Treatment was more frequently changed at SBP greater than 140 mm Hg. CONCLUSIONS: Measuring change in antihypertensive treatment using medication count frequently missed an isolated dose change in treatment modification and less often misclassified regimen modifications where there was no modification in total dose. In future research, measuring dose modification using our new algorithm would capture change in hypertension treatment intensity more precisely than current methods.

Environmental contamination with SARS-CoV-2 in nursing homes.

BACKGROUND: SARS-CoV-2 outbreaks in nursing homes (NHs) have been devastating and have led to the creation of coronavirus disease 2019 (COVID-19) units within NHs to care for affected patients. Frequency and persistence of SARS-CoV-2 environmental contamination in these units have not been studied. METHODS: A prospective cohort study was conducted between October 2020 and January 2021 in four Michigan NHs. Swabs from high-touch surfaces in COVID-19-infected patient rooms were obtained at enrollment and follow-up. Demographic and clinical data were collected from clinical records. Primary outcome of interest was the probability of SARS-CoV-2 RNA detection from specific environmental surfaces in COVID-19 patient rooms. We used multivariable logistic regression to assess patient risk factors for SARS-CoV-2 contamination. Pairwise Phi coefficients were calculated to measure correlation of site-specific environmental detection upon enrollment and during follow-up. RESULTS: One hundred and four patients with COVID-19 were enrolled (61.5% >80 years; 67.3% female; 89.4% non-Hispanic White; 51% short stay) and followed up for 241 visits. The study population had significant disabilities in activities of daily living (ADL; 81.7% dependent in four or more ADLs) and comorbidities, including dementia (55.8%), diabetes (40.4%), and heart failure (32.7%). Over the 3-month study period, 2087 swab specimens were collected (1896 COVID-19 patient rooms, 191 common areas). SARS-CoV-2 positivity was 28.4% (538/1896 swabs) on patient room surfaces and 3.7% (7/191 swabs) on common area surfaces. Nearly 90% (93/104) of patients had SARS-CoV-2 contamination in their room at least once. Environmental contamination upon enrollment correlated with contamination of the same site during follow-up. Functional independence increased the odds of proximate contamination. CONCLUSIONS: Environmental detection of viral RNA from surfaces in the rooms of COVID-19 patients is nearly universal and persistent; more investigation is needed to determine the implications of this for infectiousness. Patients with greater independence are more likely than fully dependent patients to contaminate their immediate environment.

Assessment of Preoperative Functional Status Prior to Major Head and Neck Surgery: A Pilot Study.

OBJECTIVE: To demonstrate feasibility of a recently developed preoperative assessment tool, the Vulnerable Elders Surgical Pathways and Outcomes Analysis (VESPA), to characterize the baseline functional status of patients undergoing major head and neck surgery and to examine the relationship between preoperative functional status and postoperative outcomes. STUDY DESIGN: Case series with planned data collection. SETTING: Two tertiary care academic hospitals. METHODS: The VESPA was administered prospectively in the preoperative setting. Data on patient demographics, ablative and reconstructive procedures, and outcomes including total length of stay, discharge disposition, delay in discharge, or complex discharge planning (delay or change in disposition) were collected via retrospective chart review. VESPA scores were calculated and risk categories were used to estimate risk of adverse postoperative outcomes using multivariate logistic regression for categorical outcomes and linear regression for continuous variables. RESULTS: Fifty-eight patients met study inclusion criteria. The mean (SD) age was 66.4 (11.9) years, and 58.4% of patients were male. Nearly one-fourth described preoperative difficulty in either a basic or instrumental activity of daily living, and 17% were classified as low functional status (ie, high risk) according to the VESPA. Low functional status did not independently predict length of stay but was associated with delayed discharge (odds ratio [OR], 5.0; 95% CI, 1.2-21.3; P = .030) and complex discharge planning (OR, 5.7; 95% CI, 1.34-24.2; P = .018). CONCLUSION: The VESPA can identify major head and neck surgical patients with low preoperative functional status who may be at risk for delayed or complex discharge planning. These patients may benefit from enhanced preoperative counseling and more comprehensive discharge preparation.

Interprofessional geriatric and palliative care intervention associated with fewer hospital days.

BACKGROUND: With increasing complexity of our aging inpatient population, we implemented an interprofessional geriatric and palliative care intervention on a hospitalist service. This study aimed to measure the intervention's impact on length of stay (LOS), 30-day readmission, and the daily intensity of inpatient services utilization. METHODS: Using a nonrandomized controlled intervention at a 1000-bed U.S. academic quaternary medical center, we studied 13,941 individuals admitted to a general medicine hospitalist service (of which 5644 were age > =65 years); 1483 were on intervention teams (576 age > =65 years), 5413 concurrent controls, and 7045 historical controls. On 2 of 11 hospitalist teams, a geriatrician, palliative care physician and social worker attended multidisciplinary discharge rounds twice weekly, to recommend inpatient geriatric or palliative care consult (GPCC), postacute nursing or home care, versus postdischarge outpatient consultation. We measured the difference in improvement over time between intervention and control team patients for the following: (1) LOS adjusted for case-mix index, (2) 30-day readmissions, and (3) intensity of hospital service utilization (mean services provided per patient per day). RESULTS: Adjusted LOS (in hospital days) was decreased by 0.36 days (p = 0.039) for the 1483 patients in the intervention teams, with greater LOS reduction of 0.55 days per admission (p = 0.022) on average among the subset of 576 older patient admissions. Readmissions were unchanged (-1.17%, p = 0.48 for all patients; 1.91%, p = 0.46 for older patients). However, the daily relative value unit (RVU) utilization was modestly increased for both the overall and older subgroup, 0.35 RVUs (p = 0.041) and 0.74 RVUs (p < 0.001) per patient-day on average across the intervention teams, respectively. CONCLUSION: An interprofessional intervention of geriatric and palliative care consultation in collaboration with a hospitalist service may reduce LOS, especially for geriatric patients, without an increase in readmissions. This model may have broader implications for hospital care and should be further studied.

Behaviours of older adults and caregivers preparing for elective surgery: a virtually conducted mixed-methods research protocol to improve surgical outcomes.

INTRODUCTION: Older adults (age ≥65 years) are pursuing increasingly complex, elective surgeries; and, are at higher risk for intraoperative and postoperative complications. Patients and their caregivers frequently struggle with the postoperative recovery process at home, which may contribute to complications. We aim to identify opportunities to intervene during the preoperative period to improve postoperative outcomes by understanding the preparatory behaviours of older adults and their caregivers before a complex, elective surgery. METHODS AND ANALYSIS: As a result of the COVID-19 pandemic, we will conduct this study via telephone and videoconferencing. Using a multiphase mixed-methods research design, we will collect data on 10-15 patient-caregiver dyads from a pool of older adults (across a spectrum of cognitive abilities) scheduled for an elective colorectal surgery between 1 July 2020 and 30 May 2021. We will collect quantitative and qualitative data before (T1, T2) and after (T3, T4) surgery. Preoperatively, participants will each complete a cognitive assessment and a semi-structured qualitative interview that focuses on their preparatory behaviours (T1). They will then answer questionnaires about mood, self-efficacy and home environment (T2). Three weeks following hospital discharge, participants will complete another qualitative interview focusing on a comparison of preoperative and postoperative preparedness (T3). Researchers will also collect information about the patient's medical conditions, the postoperative complications and healthcare utilisation from the patient's chart 30 days following discharge (T4). We will code and conduct thematic analysis of the qualitative data to identify salient themes. Quantitative data will be analysed using basic descriptive statistics to characterise the participants. We will integrate the qualitative and quantitative findings using results from the quantitative scales to group participants and with use of joint display analysis. ETHICS AND DISSEMINATION: Ethics approval was obtained from the University of Michigan IRB. Study findings will be disseminated through peer-reviewed journals and presentations at conferences.

Adding a New Medication Versus Maximizing Dose to Intensify Hypertension Treatment in Older Adults : A Retrospective Observational Study.

BACKGROUND: There are 2 approaches to intensifying antihypertensive treatment when target blood pressure is not reached, adding a new medication and maximizing dose. Which strategy is better is unknown. OBJECTIVE: To assess the frequency of intensification by adding a new medication versus maximizing dose, as well as the association of each method with intensification sustainability and follow-up systolic blood pressure (SBP). DESIGN: Large-scale, population-based, retrospective cohort study. Observational data were used to emulate a target trial with 2 groups, new medication and maximizing dose, who underwent intensification of their drug regimen. SETTING: Veterans Health Administration (2011 to 2013). PATIENTS: Veterans aged 65 years or older with hypertension, an SBP of 130 mm Hg or higher, and at least 1 antihypertensive medication at less than the maximum dose. MEASUREMENTS: The following 2 intensification approaches were emulated: adding a new medication, defined as a total dose increase with new medication, and maximizing dose, defined as a total dose increase without new medication. Inverse probability weighting was used to assess the observational effectiveness of the intensification approach on sustainability of intensified treatment and follow-up SBP at 3 and 12 months. RESULTS: Among 178 562 patients, 45 575 (25.5%) had intensification by adding a new medication and 132 987 (74.5%) by maximizing dose. Compared with maximizing dose, adding a new medication was associated with less intensification sustainability (average treatment effect, -15.2% [95% CI, -15.7% to -14.6%] at 3 months and -15.1% [CI, -15.6% to -14.5%] at 12 months) but a slightly larger reduction in mean SBP (-0.8 mm Hg [CI, -1.2 to -0.4 mm Hg] at 3 months and -1.1 mm Hg [CI, -1.6 to -0.6 mm Hg] at 12 months). LIMITATION: Observational data; largely male population. CONCLUSION: Adding a new antihypertensive medication was less frequent and was associated with less intensification sustainability but slightly larger reductions in SBP. Trials would provide the most definitive support for our findings. PRIMARY FUNDING SOURCE: National Institute on Aging and Veterans Health Administration.

Effectiveness of a Multicomponent Intervention to Reduce Multidrug-Resistant Organisms in Nursing Homes: A Cluster Randomized Clinical Trial.

Importance: Multidrug-resistant organisms (MDROs) can cause significant morbidity and mortality. Preventing MDROs can reduce the risk of subsequent transmission and infection. Objective: To determine whether a multicomponent infection prevention intervention can reduce MDRO prevalence in nursing homes (NHs). Design, Setting, and Participants: This cluster randomized clinical trial of a multicomponent intervention was conducted in 6 NHs in Michigan from September 2016 to August 2018. Three NHs adopted a multicomponent intervention, while 3 control NHs continued without investigator intervention. Study visits were conducted at baseline; days 7, 14, 21, and 30; and monthly thereafter for up to 6 months or discharge. Visits included clinical data collection and MDRO surveillance culturing of multiple body sites and high-touch surfaces in patient rooms. Any patients who provided informed consent within 14 days of admission to the NH were enrolled in this study. Non-English speakers and patients receiving hospice care were ineligible. Analysis was performed from November 2018 to February 2020. Interventions: Intervention NHs adopted a multicomponent intervention that included enhanced barrier precautions, chlorhexidine bathing, MDRO surveillance, environmental cleaning education and feedback, hand hygiene promotion, and health care worker education and feedback. Control nursing homes continued standard care practices. Main Outcomes and Measures: The primary outcome, presence of MDROs, was measured longitudinally in the patient and room environment and was evaluated using generalized mixed effect models. The secondary outcome, time to new MDRO acquisition, was assessed using Cox proportional hazard models. Results: A total of 6 NHs were included, with 245 patients (mean [SD] age, 72.5 [13.6] years; 134 [54.7%] women) enrolled; 3 NHs with 113 patients (46.1%) were randomized to the intervention group and 3 NHs with 132 patients (53.9%) were randomized to the control group. A total of 132 patients (53.9%) were White, and 235 patients (95.9%) were receiving postacute care. Over 808 study visits, 3654 patient cultures and 5606 environmental cultures were obtained. The intervention reduced the odds of MDRO prevalence in patients' environment by 43% (aOR, 0.57; 95% CI, 0.35-0.94), but there was no statistically significant difference on the patient level before or after adjustment (aOR, 0.57; 95% CI, 0.29-1.14). There were no significant reductions in time to new acquisition for methicillin-resistant Staphylococcus aureus (hazard ratio [HR], 0.20; 95% CI, 0.04-1.09), vancomycin-resistant enterococci (HR, 0.84; 95% CI, 0.46-1.53), or resistant gram-negative bacilli (HR, 1.14; 95% CI, 0.73-1.78). Conclusions and Relevance: This cluster randomized clinical trial found that the multicomponent intervention reduced the prevalence of MDROs in the environment of NH patients. Our findings highlight the potential for multicomponent interventions to directly and indirectly reduce MDRO prevalence in NHs. Trial Registration: ClinicalTrials.gov Identifier: NCT02909946.

Factors associated with antihypertensive treatment intensification and deintensification in older outpatients.

BACKGROUND: New hypertension performance measures encourage more intensive treatment in older adults. Treatment intensification includes starting new medications and increasing the dose of old ones. Medication dose is particularly important to older adults, given their vulnerability to dose-related side effects. We previously validated a standardized measure of beneficial doses tested in hypertension trials, Hypertension Daily Dose (HDD). AIM OF THE STUDY: To test whether changes in treatment intensity using HDD was associated with systolic blood pressure (SBP) and patient characteristics. METHODS: Longitudinal study of all Veterans aged ≥65 years with a diagnosis of hypertension. We defined 3 groups of risk: 1) cardiovascular risk; 2) geriatric/frail; 3) low-risk (comparator). Using multinomial regression, we assessed the probability of deintensification, intensification, vs. stable treatment, according to SBP and group. RESULTS: Among 1,331,111 Veterans, 19.9% had deintensification, and 29.6% intensification. Deintensification decreased, while intensification increased, with SBP. Compared to low-risk patients, cardiovascular risk patients had 1.11 (95% CI 1.10-1.13) times the odds of intensifying, and geriatric/frail patients 1.45 (95%CI 1.43-1.47) times the odds of deintensifying. DISCUSSION: Patient-level HDD change was consistent with an expected association with cardiovascular risk and geriatric/frail conditions, suggesting that HDD can be used longitudinally to assess hypertension treatment modification in large health systems.