Are the benefits of advance care planning for care home residents, as demonstrated by research studies, seen when implemented in a large-scale clinical service offering advance care planning for care home residents as part of Comprehensive Geriatric Assessment (CGA)?

Introduction Care home residents have a short life expectancy and are more likely to have emergency admissions than people of the same age living in the community. Although such admissions may resolve crises, maintain and restore functional and relieve physical and mental distress, there is evidence that hospital admission may be burdensome or detrimental to the health of older people with severe frailty. Furthermore, admission may not reflect their wishes, or those of their families. Advance care planning is a means by which care home residents can express their health care preferences, not only regarding admission to hospital, but also their choices in relation to other aspects of their care. I conducted a systematic review which found that some research studies showed that advance care planning for care home residents was associated with reduced hospital admissions and increased proportions dying in the care home. The evidence appeared stronger for advance care planning educational interventions than interventions delivered by specialist teams, but there was much less evidence as to whether these findings could be replicated in routine practice. Aims The research questions this thesis asked was whether Advance Care Plans (ACPs): • could be implemented in unselected care homes • were acceptable to care home residents • were associated with reduced hospital admissions • were associated with more residents dying in their preferred place of care. Methods To test this research question, a service was implemented and evaluated in Lincoln, UK. The intervention involved a multidisciplinary team trained in comprehensive geriatric assessment and the use of ACPs and led by me. The effect of this service on hospital admissions was evaluated using a step wedge randomised control designed study, under clinical governance, using routine hospital and mortality data. The extent to which the intervention was delivered was evaluated using routine service records. A trustworthiness framework was used justify the credibility, dependability, confirmability, transferability and authenticity of the use of field notes, multidisciplinary team meeting and diary records, and reports from residents’ electronic primary care records obtained during the implementation and delivery of the service and the results of the quantitative study to formulate retrospectively a synthesis using soft systems methodology and a widely used framework for understanding service implementation, the Consolidated Framework for Implementation Research. Results I found that: • Advance care planning could be implemented in 68% of care homes • ACPs were acceptable to almost 80% of residents, similar levels to research trials • the intervention did not lead to a reduction in hospital admissions, but rather a trend towards increased admissions • Possession of an ACP was associated with a greater chance of dying in the care home which, for most residents, was their preferred place of care • Residents were more likely to opt for active medical treatment while their function remained good, whereas residents with greater frailty were more likely to emphasise preference for palliative care The synthesis illustrated that, in implementation of the project, multiple interfaces needed to be considered, including individual residents, their families, care homes and general practices, local health and social care organisations, and the wider context of a whole system experiencing increasing financial constraint and organisational change. Discussion This service successfully delivered ACPs alongside a comprehensive geriatric assessment, although not all care home managers co-operated. Most residents in whom ACPs were put in place opted for their preferred place of death to be the care home, and having an ACP increased the likelihood of doing so. However, hospital admissions were not reduced. Although advance care planning is not a new concept to palliative care in the UK, most NHS staff, and the Lincolnshire population, were unfamiliar with the concept. Thus, implementation of a relatively novel concept for residents of care homes in Lincoln presented challenges. Importantly, care home residents were able to have their choices formalised and communicated to stakeholders, including primary care and out of hours services. The failure to demonstrate a reduction in admissions was likely to reflect several factors, including residents’ choice for active intervention, and lack of community services to support implementation of ACPs. However, in a climate of economic austerity, no reduction in admissions has implications for future funding and sustainability of advance care planning. The importance of proactive use of implementation science models for future implementation is proposed

The prevalence of malnutrition (MUST and MNA-SF), frailty and physical disability and relationship with mortality in older care home residents

Background & Aims: Currently, there is lack of universal consensus on the use of effective malnutrition screening tools. Although malnutrition, frailty and physical disability are interrelated and associated with mortality in older people, there is a paucity of research in care home settings. With a high co-prevalence of these conditions, understanding their interconnectedness can provide a holistic view of an older person's health condition. The purpose of this study was to examine the prevalence of malnutrition (and risk) frailty and physical disability among care home residents using different methods, as well as the associations between markers of malnutrition (MUST and MNA-SF), physical function (Barthel Index, BI), frailty (Edmonton Frailty Scale, EFS), and all-cause mortality in care home residents.// Methods: In Lincoln, UK, 508 residents from care homes underwent screening for malnutrition (MNA-SF and MUST), frailty (EFS), and physical function (BI) as part of standard comprehensive geriatric assessment (CGA) between November 2015 and January 2018. Prevalence of conditions were assessed and MNA-SF, MUST, EFS, and BI-specific survival in each category were compared using Kaplan-Meier survival analysis (KMSA) with log-rank test. Multivariable analyses were conducted using the Cox proportional hazard model to identify prognostic factors that were statistically significant in care home residents.// Results: There was significant discordance between malnutrition risk measured by MUST and MNA-SF. The percentage of patients ‘at risk’/‘medium risk’ and ‘malnourished’/‘high risk’ was 25.3%/49.9% for MNA and for 19.6%/31.57% for MUST. The prevalence of frailty measured by EFS was high with the percentage of residents with severe frailty being 70.9%. Only 8.6% of patients were functionally independent. The association between malnutrition risk (MUST) and mortality was not significant. MNA-SF appeared to be a better tool at predicting mortality in older care home residents (p < 0.001). Furthermore, the association between frailty (EFS) and mortality was significant (p < 0.01).// Conclusions: This study found high levels of malnutrition, frailty, and disability among UK care home residents, and a discordance between MUST and MNA-SF scoring patterns. The MNA-SF and EFS were better predictors of mortality than MUST and BI, highlighting the need for sensitive tools in assessing malnutrition and frailty risks in this population

Are the benefits of advance care planning for care home residents, as demonstrated by research studies, seen when implemented in a large-scale clinical service offering advance care planning for care home residents as part of Comprehensive Geriatric Assessment (CGA)?

Introduction Care home residents have a short life expectancy and are more likely to have emergency admissions than people of the same age living in the community. Although such admissions may resolve crises, maintain and restore functional and relieve physical and mental distress, there is evidence that hospital admission may be burdensome or detrimental to the health of older people with severe frailty. Furthermore, admission may not reflect their wishes, or those of their families. Advance care planning is a means by which care home residents can express their health care preferences, not only regarding admission to hospital, but also their choices in relation to other aspects of their care. I conducted a systematic review which found that some research studies showed that advance care planning for care home residents was associated with reduced hospital admissions and increased proportions dying in the care home. The evidence appeared stronger for advance care planning educational interventions than interventions delivered by specialist teams, but there was much less evidence as to whether these findings could be replicated in routine practice. Aims The research questions this thesis asked was whether Advance Care Plans (ACPs): • could be implemented in unselected care homes • were acceptable to care home residents • were associated with reduced hospital admissions • were associated with more residents dying in their preferred place of care. Methods To test this research question, a service was implemented and evaluated in Lincoln, UK. The intervention involved a multidisciplinary team trained in comprehensive geriatric assessment and the use of ACPs and led by me. The effect of this service on hospital admissions was evaluated using a step wedge randomised control designed study, under clinical governance, using routine hospital and mortality data. The extent to which the intervention was delivered was evaluated using routine service records. A trustworthiness framework was used justify the credibility, dependability, confirmability, transferability and authenticity of the use of field notes, multidisciplinary team meeting and diary records, and reports from residents’ electronic primary care records obtained during the implementation and delivery of the service and the results of the quantitative study to formulate retrospectively a synthesis using soft systems methodology and a widely used framework for understanding service implementation, the Consolidated Framework for Implementation Research. Results I found that: • Advance care planning could be implemented in 68% of care homes • ACPs were acceptable to almost 80% of residents, similar levels to research trials • the intervention did not lead to a reduction in hospital admissions, but rather a trend towards increased admissions • Possession of an ACP was associated with a greater chance of dying in the care home which, for most residents, was their preferred place of care • Residents were more likely to opt for active medical treatment while their function remained good, whereas residents with greater frailty were more likely to emphasise preference for palliative care The synthesis illustrated that, in implementation of the project, multiple interfaces needed to be considered, including individual residents, their families, care homes and general practices, local health and social care organisations, and the wider context of a whole system experiencing increasing financial constraint and organisational change. Discussion This service successfully delivered ACPs alongside a comprehensive geriatric assessment, although not all care home managers co-operated. Most residents in whom ACPs were put in place opted for their preferred place of death to be the care home, and having an ACP increased the likelihood of doing so. However, hospital admissions were not reduced. Although advance care planning is not a new concept to palliative care in the UK, most NHS staff, and the Lincolnshire population, were unfamiliar with the concept. Thus, implementation of a relatively novel concept for residents of care homes in Lincoln presented challenges. Importantly, care home residents were able to have their choices formalised and communicated to stakeholders, including primary care and out of hours services. The failure to demonstrate a reduction in admissions was likely to reflect several factors, including residents’ choice for active intervention, and lack of community services to support implementation of ACPs. However, in a climate of economic austerity, no reduction in admissions has implications for future funding and sustainability of advance care planning. The importance of proactive use of implementation science models for future implementation is proposed

Investigating the prevalence of malnutrition, frailty and physical disability and the association between them amongst older care home residents

BACKGROUND: Malnutrition, frailty and physical disability are inter-related, more prevalent in the older population and increase the risk of adverse health outcomes. Thus, screening is essential, especially in the understudied care home setting where the population is vulnerable and at higher risk of malnutrition. Furthermore, prevalence may vary depending upon screening tools used. The aims of this study were to: 1) investigate the prevalence of 1) malnutrition risk using Mini Nutritional Assessment - Short Form (MNA-SF) and Malnutrition Universal Screening Tool (MUST), 2) frailty using the Edmonton Frailty Scale (EFS), 3) physical disability using the Barthel Index (BI) and (4) examine the association between variables and coexistence of states. METHODS: Screening for malnutrition (MNA-SF and MUST) and frailty (EFS) was performed as part of a comprehensive geriatric assessment (CGA) in 527 residents from 17 care homes in Lincoln, UK. Mean age of the group was 85.6 ± 7.6 years and body mass index, BMI 23.0 ± 5.1 kg/m2. RESULTS: A high prevalence of malnutrition risk was detected: 41.4% by MNA-SF and 25.5% by MUST (high risk/malnourished). Furthermore, there was a clear discordance between MNA-SF and MUST scoring of malnutrition; for example, the percentage of those identified as being at low risk was 18.8% using the MNA-SF and 57.0% using the MUST. In addition, there was a high prevalence of severe frailty by EFS (69.6%) and functional impairment by BI (62.0%). There was good association between some variables (P < 0.001) and 33.4% of residents had coexistence of all three states of malnutrition, frailty and physical disability. CONCLUSIONS: Malnutrition risk, frailty and physical disability are highly prevalent in care home residents and interrelated. However, prevalence varies depending on the screening tool used. More research should be conducted in the care home setting to improve daily clinical practice as screening may impact upon subsequent treatment and care modalities and clinical outcomes

Advance Care Plans in UK care home residents: a service evaluation using a stepped wedge design

Introduction Advance care planning (ACP) in care homes has high acceptance, increases the proportion of residents dying in place and reduces hospital admissions in research. We investigated whether ACP had similar outcomes when introduced during real-world service implementation. Methods A service undertaking ACP in Lincoln, UK care homes was evaluated using routine data. Outcomes were proportion of care homes and residents participating in ACP; characteristics of residents choosing/declining ACP; and place of death for those with/without ACP. Hospital admissions were analysed using mixed-effects Poisson regression for number of admissions, and a mixed-effects negative binomial model for number of occupied hospital bed days. Results15/24 (63%) eligible homes supported the service, in which 404/508 (79.5%) participants chose ACP. Residents choosing ACP were older, frailer, more cognitively impaired and malnourished. 384/404 (95%) residents choosing ACP recorded their care home as their preferred place of death: 380/404 (94%) declined cardiopulmonary resuscitation. Among deceased residents, 219/248 (88%) and 33/49 (67%) with and without advance care plan respectively died in their care home (relative risk 1.35, 95%CI 1.1-1.6, p<0.001). Hospital admission rates and bed occupancy did not differ after implementation. Discussion 79.5% participants chose ACP. Those doing so were more likely to die at home. Many homes were unwilling or unable to support the service. Further research should consider how to enlist the support of these homes. Hospital admissions were not reduced and may not be an appropriate outcome metric for ACP in care homes

Macroscopic non-equilibrium thermodynamics in dynamic calorimetry

What is really measured in dynamic calorimetric experiments is still an open question. This paper is devoted to this question, which can be usefully envisaged by means of macroscopic non-equilibrium thermodynamics. From the pioneer work of De Donder on chemical reactions and with other authors along the 20th century, the question is tackled under an historical point of view. A special attention is paid about the notions of frequency dependent complex heat capacity and entropy production due to irreversible processes occurring during an experiment. This phenomenological approach based on thermodynamics, not widely spread in the literature of calorimetry, could open significant perspectives on the study of macro-systems undergoing physico-chemical transformations probed by dynamic calorimetry.Comment: review article (21 pages

Intravesical device-assisted therapies for non-muscle-invasive bladder cancer

Non-muscle-invasive bladder cancer (NMIBC), the most prevalent type of bladder cancer, accounts for ~75% of bladder cancer diagnoses. This disease has a 50% risk of recurrence and 20% risk of progression within 5 years, despite the use of intravesical adjuvant treatments (such as BCG or mitomycin C) that are recommended by clinical guidelines. Intravesical device-assisted therapies, such as radiofrequency-induced thermochemotherapeutic effect (RITE), conductive hyperthermic chemotherapy, and electromotive drug administration (EMDA), have shown promising efficacy. These device-assisted treatments are an attractive alternative to BCG, as issues with supply have been a problem in some countries. RITE might be an effective treatment option for some patients who have experienced BCG failure and are not candidates for radical cystectomy. Data from trials using EMDA suggest that it is effective in high-risk disease but requires further validation, and results of randomized trials are eagerly awaited for conductive hyperthermic chemotherapy. Considerable heterogeneity in patient cohorts, treatment sessions, use of maintenance regimens, and single-arm study design makes it difficult to draw solid conclusions, although randomized controlled trials have been reported for RITE and EMDA

Dimethyl fumarate in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Dimethyl fumarate (DMF) inhibits inflammasome-mediated inflammation and has been proposed as a treatment for patients hospitalised with COVID-19. This randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple treatments in patients hospitalised for COVID-19 (NCT04381936, ISRCTN50189673). In this assessment of DMF performed at 27 UK hospitals, adults were randomly allocated (1:1) to either usual standard of care alone or usual standard of care plus DMF. The primary outcome was clinical status on day 5 measured on a seven-point ordinal scale. Secondary outcomes were time to sustained improvement in clinical status, time to discharge, day 5 peripheral blood oxygenation, day 5 C-reactive protein, and improvement in day 10 clinical status. Between 2 March 2021 and 18 November 2021, 713 patients were enroled in the DMF evaluation, of whom 356 were randomly allocated to receive usual care plus DMF, and 357 to usual care alone. 95% of patients received corticosteroids as part of routine care. There was no evidence of a beneficial effect of DMF on clinical status at day 5 (common odds ratio of unfavourable outcome 1.12; 95% CI 0.86-1.47; p = 0.40). There was no significant effect of DMF on any secondary outcome

Dimethyl fumarate in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Dimethyl fumarate (DMF) inhibits inflammasome-mediated inflammation and has been proposed as a treatment for patients hospitalised with COVID-19. This randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple treatments in patients hospitalised for COVID-19 (NCT04381936, ISRCTN50189673). In this assessment of DMF performed at 27 UK hospitals, adults were randomly allocated (1:1) to either usual standard of care alone or usual standard of care plus DMF. The primary outcome was clinical status on day 5 measured on a seven-point ordinal scale. Secondary outcomes were time to sustained improvement in clinical status, time to discharge, day 5 peripheral blood oxygenation, day 5 C-reactive protein, and improvement in day 10 clinical status. Between 2 March 2021 and 18 November 2021, 713 patients were enroled in the DMF evaluation, of whom 356 were randomly allocated to receive usual care plus DMF, and 357 to usual care alone. 95% of patients received corticosteroids as part of routine care. There was no evidence of a beneficial effect of DMF on clinical status at day 5 (common odds ratio of unfavourable outcome 1.12; 95% CI 0.86-1.47; p = 0.40). There was no significant effect of DMF on any secondary outcome