Ten vs five years of bisphosphonate treatment for postmenopausal osteoporosis: enough of a good thing.
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Aged↗
Biomedical subjects
Cathleen S Colón-Emeric
Publications and source records attributed to Cathleen S Colón-Emeric.
Osteoporotic fractures in older adults.
Osteoporotic fractures are emerging as a major public health problem in the aging population. Fractures result in increased morbidity, mortality and health expenditures. This article reviews current evidence for the management of common issues following osteoporotic fractures in older adults including: (1) thromboembolism prevention; (2) delirium prevention; (3) pain management; (4) rehabilitation; (5) assessing the cause of fracture; and (6) prevention of subsequent fractures. Areas for practice improvement and further research are highlighted.
Aged↗
Exit interview-consultation for research validation and dissemination.
Dissemination of research findings to practice and maintenance of rigor and validity in qualitative research are continuing challenges for nurse researchers. Using three nursing home case studies as examples, this article describes how exit interview-consultation was used as (a) a validation strategy and (b) a rapid research dissemination tool that is particularly useful for nursing systems research. Through an exit interview-consultation method, researchers validated inferences made from qualitative and quantitative data collected in three comprehensive nursing home case studies that examined nursing management practices. This exit interview-consultation strategy extends the traditional member-check approach by providing confirmation at the individual and organizational level. The study examined how using the exit interview-consultation strategy can potentially assist nursing home organizations to increase their capacity for improving operations. Benefits from research participation are often indirect; this study's results suggest that exit interview-consultation can provide direct and immediate benefits to organizations and individuals.
Consultants↗
MDS coordinator relationships and nursing home care processes.
This study describes how Minimum Data Set (MDS) coordinators' relationship patterns influence nursing home care processes. MDS coordinators interact with nursing home staff to coordinate resident assessment and care planning, but little is known about how they enact this role or influence particular care processes beyond paper compliance. Guided by complexity science and using two nursing home case studies, the authors describe MDS coordinators' relationship patterns by assessing the extent to which they used and fostered good connections, new information flow, and cognitive diversity. MDS coordinators at one site fostered new information flow, good connections, and cognitive diversity, which positively influenced assessment and care planning, whereas those at the other site did little to foster these three relationship parameters, with little influence on care processes. This study revealed that MDS coordinators are an important new source of capacity for the nursing home industry to improve quality of care.
Aged↗
Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science.
Complexity science teaches that relationships among health care providers are key to our understanding of how quality care emerges. The authors sought to compare the effects of differing patterns of medicine-nursing communication on the quality of information flow, cognitive diversity, self-organization, and innovation in nursing homes. Two facilities participated in 6-month case studies using field observations, shadowing, and depth interviews. In one facility, the dominant pattern of communication was a vertical "chain of command" between care providers, characterized by thin connections and limited information exchange. This pattern limited cognitive diversity and innovation in clinical problem solving. The second facility used an open communication pattern between medical and frontline staff. The authors saw higher levels of information flow, cognitive diversity, innovation, and self-organization, although tempered by staff turnover. The patterns of communication between care providers in nursing facilities have an important impact on their ability to provide quality, innovative care.
Communication↗
Antiresorptive pharmacotherapy in older women: where the evidence-based medicine rubber meets the geriatrics road.
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Aged↗
Does this woman have osteoporosis?
CONTEXT: Although recent US Preventive Services Task Force guidelines recommend bone densitometry for all women older than 65 years, identifying younger women at increased risk for osteoporosis and women with occult vertebral fractures remains a clinical challenge. We investigated whether physical signs are useful as a screening tool either for early referral to bone densitometry or for occult spinal fractures. OBJECTIVE: To review the accuracy and precision of physical examination findings for the diagnosis of osteopenia, osteoporosis, or spinal fracture. DATA SOURCES: We conducted a MEDLINE search for articles published from 1966 through August 2004, manually reviewed bibliographies, consulted 4 clinical skills textbooks, and contacted experts in the field. STUDY SELECTION: Studies were included if they contained adequate original data on the accuracy or precision of physical examination for diagnosing osteopenia, osteoporosis, or spinal fracture. Two authors screened abstracts found by the search. Fourteen of 191 full articles reviewed met inclusion criteria. DATA EXTRACTION: Two authors independently abstracted data from the included studies. Disagreements were resolved by discussion. DATA SYNTHESIS: No single maneuver is sufficient to rule in or rule out osteoporosis or spinal fracture without further testing. The following yielded the greatest positive likelihood ratios (LR+): weight less than 51 kg, LR+, 7.3 (95% confidence interval [CI], 5.0-10.8); tooth count less than 20, LR+, 3.4 (95% CI, 1.4-8.0); rib-pelvis distance less than 2 finger breadths, LR+, 3.8 (95% CI, 2.9-5.1); wall-occiput distance greater than 0 cm, LR+, 4.6 (95% CI, 2.9-7.3), and self-reported humped back, LR+, 3.0 (95% CI, 2.2-4.1). CONCLUSIONS: In patients who do not meet current bone mineral density screening recommendations, several convenient examination maneuvers, especially low weight, can significantly change the pretest probability of osteoporosis and suggest the need for earlier screening. Wall-occiput distance greater than 0 cm and rib-pelvis distance less than 2 fingerbreadths suggest the presence of occult spinal fracture.
Absorptiometry, Photon↗
The HORIZON Recurrent Fracture Trial: design of a clinical trial in the prevention of subsequent fractures after low trauma hip fracture repair.
OBJECTIVE: To present the novel design of a trial testing the safety and efficacy of a yearly bisphosponate, zoledronic acid, in preventing new clinical fractures in patients with recent low trauma hip fracture repair. RESEARCH DESIGN AND METHODS: Randomized, placebo-controlled, triple-blind study. One hundred and fifteen clinical centers worldwide are recruiting approximately 1714 subjects aged 50 years and over (no upper age limit, median age of enrolled subjects to date 79 years) who have undergone surgical repair of a low trauma hip fracture in the preceding 90 days. Patients will be assigned at random to an intervention group (5 mg zoledronic acid intravenously yearly) or a control group (placebo infusion yearly). Both groups receive a loading dose of Vitamin D2 or D3 IM or orally, followed by 800-1200 IU Vitamin D and 1000-1500 mg elemental calcium orally on a daily basis. Concomitant therapy with calcitonin, hormone replacement therapy, selective estrogen receptor modulators, tibolone, and external hip protectors are allowed. MAIN OUTCOME MEASURES: The primary endpoint is subsequent skeletal fractures as adjudicated by a clinical endpoints committee blinded to intervention status. Secondary outcomes include delayed hip fracture healing, changes in bone mineral density, and health resource utilization. Subjects will be recruited over a 3-4 year period and will be followed until 211 primary endpoints are accrued and adjudicated. CONCLUSIONS: This randomized clinical trial is novel among osteoporosis therapies as it (1). targets hip fracture patients, a previously understudied group, and (2). uses only clinically evident fractures as the primary outcome. Ethical and practical considerations in studying this frail population are discussed.
Bone Density↗
Risk factors for hip fracture in skilled nursing facilities: who should be evaluated?
This paper aims to identify risk factors for hip fracture in Medicare skilled nursing facility (SNF) residents and to develop a predictive model based on routinely collected administrative data (the Minimum Data Set, MDS) to identify high-risk residents. Prospective cohort study of 28,807 North Carolina Medicare SNF residents aged >65 years with a complete MDS assessment in 1999. Demographic, historical, physical, cognitive, behavioral, activities of daily living, and medication variables were obtained from the MDS. Hip fracture occurring after the first MDS assessment identified by ICD-9 code was the outcome measure. Variables significantly associated with hip fracture by chi-square test in a randomly selected derivation sample were combined in a multivariable logistic model and in models stratified by gender. The models were validated in the remaining subjects. Variables significantly related to subsequent hip fracture in the full cohort include: female sex (odds ratio 1.3, 95% confidence interval 1.0-1.7), white race (2.3, 1.6-3.5), age (1.03 per year, 1.01-1.04), cognitive impairment (1.4, 1.8-1.8), incontinence (0.68, 0.5-0.9), prior fractures (1.6, 1.2-2.1), and prior falls (1.4, 1.2-1.8). In ambulatory non-Hispanic white women, anxiety (1.5, 1.0-2.1), anxiolytic use (1.4, 1.1-1.9), wandering (1.4, 1.0-2.2), and training in community skills (1.4, 1.1-1.8) were new significant variables. For ambulatory non-Hispanic white men, education level (2.0, 1.2-3.2), weight loss (0.5, 0.2-1.0), history of osteoporosis (3.0, 1.3-6.7), pathologic bone fracture (9.7, 2.2-42.6), COPD (2.1, 1.3-3.5), glaucoma (2.6, 1.0-6.2), and standing balance impairment (1.8, 1.0-3.3) were also significant. All models were highly correlated with subsequent hip fracture, but the discriminative ability was limited (c statistic 0.678). Risk factors explained more of hip fracture risk in non-Hispanic white men (c statistic 0.793) than non-Hispanic white women (0.658). Risk factors for hip fracture in Medicare SNF residents have similarities and differences from those previously identified in community-dwelling older adults. Osteoporosis screening and intervention should focus on the healthiest, most independent subset of residents who have the greatest fracture risk.
Activities of Daily Living↗
An economic analysis of external hip protector use in ambulatory nursing facility residents.
OBJECTIVE: to evaluate the economic impact of external hip protector use in nursing facilities. DESIGN: cost-effectiveness and cost-utility analyses. MEASUREMENTS: event probabilities, intervention effectiveness, treatment costs, and utility of hip fracture state were determined from peer-reviewed medical literature and public use data. METHODS: a societal perspective with an 18-month time horizon was used. A decision tree model was constructed. Expected cost, effectiveness, and incremental cost-effectiveness ratio were calculated. One and two-way sensitivity analyses and threshold analyses were performed. RESULTS: the strategy of using external hip protectors saves approximately US$300 per subject and adds 0.01 quality adjusted life year over 18 months. The model remains dominant over the entire range of input values for all variables except the cost of hip protectors. At the maximum estimated cost of US$695/subject/18 months, the incremental cost-effectiveness ratio was $30,600/quality adjusted life year. The strategy of using hip protectors was cost saving or cost neutral if the cost of hip protector strategy is <or=US$397/subject/18 months. CONCLUSIONS: using external hip protectors in nursing facilities is cost saving or economically attractive over a wide range of cost and utility assumptions.
Aged↗
Can we identify women at high risk of osteoporotic fractures?
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Adult↗
Barriers to providing osteoporosis care in skilled nursing facilities: perceptions of medical directors and directors of nursing.
OBJECTIVES: The objectives of this study were to identify the barriers to osteoporosis clinical practice guideline use perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in skilled nursing facilities; and to describe differences in the perceptions of MED DIRs and DONs. DESIGN: The authors conducted a cross-sectional national survey. PARTICIPANTS: This study consisted of a random national sample of MED DIRs (n = 1300) and DONs (n = 1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-term Care. MEASUREMENTS: A 24-item survey using a five-point Likert scale was developed. The survey measured agreement to questions in four domains (provider factors, guideline characteristics, patient factors, environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). Response distributions to each item were plotted and differences between MED DIRs and DONs were tested. RESULTS: Survey response rates were 40% for MED DIRs and 48% for DONs. Respondents strongly agreed that fractures are a problem in their facilities and that osteoporosis guidelines are useful and cost-beneficial (mean responses > or = 4.0). A large proportion of respondents (at least 40% of the sample) identified multiple patient comorbidities, reimbursement issues, length of stay, and regulatory oversight as barriers to providing osteoporosis care. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concerns about bisphosphonate safety were barriers to osteoporosis care. DONs were more likely than MED DIRs to believe that patients and families are concerned about fractures, whereas MED DIRs were more likely to endorse length of stay, staffing issues, and regulatory oversight as influencing treatment decisions. Years of practice and facility size, but not formal geriatrics training, significantly influenced responses. CONCLUSION: Perceived barriers to implementing osteoporosis guidelines differ between facilities and between MED DIRs and DONs. Identification of these barriers could facilitate quality improvement initiatives and improve the quality of osteoporosis care.
Aged↗
Connection, regulation, and care plan innovation: a case study of four nursing homes.
We describe how connections among nursing home staff impact the care planning process using a complexity science framework. We completed six-month case studies of four nursing homes. Field observations (n = 274), shadowing encounters (n = 69), and in-depth interviews (n = 122) of 390 staff at all levels were conducted. Qualitative analysis produced a conceptual/thematic description and complexity science concepts were used to produce conceptual insights. We observed that greater levels of staff connection were associated with higher care plan specificity and innovation. Connection of the frontline nursing staff was crucial for (1) implementation of the formal care plan and (2) spontaneous informal care planning responsive to changing resident needs. Although regulations could theoretically improve cognitive diversity and information flow in care planning, we observed instances of regulatory oversight resulting in less specific care plans and abandonment of an effective care planning process. Interventions which improve staff connectedness may improve resident outcomes.
Diffusion of Innovation↗
Barriers to providing osteoporosis care in skilled nursing facilities: perceptions of medical directors and directors of nursing.
OBJECTIVES: The objectives of this study were to identify the barriers to osteoporosis clinical practice guideline use perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in skilled nursing facilities; and to describe differences in the perceptions of MED DIRs and DONs. DESIGN: The authors conducted a cross-sectional national survey. PARTICIPANTS: This study consisted of a random national sample of MED DIRs (n=1300) and DONs (n=1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-term Care. MEASUREMENTS: A 24-item survey using a five-point Likert scale was developed. The survey measured agreement to questions in four domains (provider factors, guideline characteristics, patient factors, environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). Response distributions to each item were plotted and differences between MED DIRs and DONs were tested. RESULTS: Survey response rates were 40% for MED DIRs and 48% for DONs. Respondents strongly agreed that fractures are a problem in their facilities and that osteoporosis guidelines are useful and cost-beneficial (mean responses > or = 4.0). A large proportion of respondents (at least 40% of the sample) identified multiple patient comorbidities, reimbursement issues, length of stay, and regulatory oversight as barriers to providing osteoporosis care. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concerns about bisphosphonate safety were barriers to osteoporosis care. DONs were more likely than MED DIRs to believe that patients and families are concerned about fractures, whereas MED DIRs were more likely to endorse length of stay, staffing issues, and regulatory oversight as influencing treatment decisions. Years of practice and facility size, but not formal geriatrics training, significantly influenced responses. CONCLUSION: Perceived barriers to implementing osteoporosis guidelines differ between facilities and between MED DIRs and DONs. Identification of these barriers could facilitate quality improvement initiatives and improve the quality of osteoporosis care.
Attitude of Health Personnel↗