Rigor and reproducibility training for first year medical students in research pathways

In the Spring of 2020, we launched a rigor and reproducibility curriculum for medical students in research training programs. This required class consisted of eight, two-hour sessions which transitioned to remote learning in response to the COVID-19 epidemic. The class was graded as Pass/Fail. Flipped classroom techniques, with multiple hands-on exercises, were developed for first year medical students (MD/PhD (n=9), Clinical and Translational Research Pathway students (n=9)). Four focus groups (n=13 students) and individual interviews with the two instructors were conducted in May 2020. From individual interviews with instructors and focus groups with medical students, the course and its components were favorably reviewed. Students thought the course was novel, important, relevant, and practical - and teaching strategies were effective (e.g., short lectures, interactive small group exercises, project). Most students expressed concerns about lack of time for course prep. Sharper focus and streamlining of prep work may be required. Pre- and post- student self-assessments of rigor and reproducibility competencies showed average post-scores ranging from high/moderate to strong understanding (n=11). We conclude that rigor and reproducibility can be taught to first year medical students in research pathways programs in a highly interactive and remote format

Residential modifications and decline in physical function among community-dwelling elderly

PURPOSE: The purpose of this study is to quantify the effect of residential modification on decreasing risk of physical function decline in 2 years. DESIGN: Cohort study using propensity scores method to control for baseline differences between individuals with residential modifications and those without residential modifications. PARTICIPANTS: Participants (N = 9,447) were from the Second Longitudinal Study on Aging, a nationally representative sample of the civilian noninstitutionalized population, aged 70 years and older in the United States at the time of baseline interview in 1994-1995. METHODS: Participants self-reported residential modifications at baseline (e.g., railings, bathroom modifications). Decline in physical functioning was measured by comparing self-reported activities of daily living at baseline and at 2-year follow-up. RESULTS: Compared with individuals without baseline modifications, a higher proportion of those with baseline modifications were aged 85 years and older (16% vs. 10%), used special aides (36% vs. 14%), and lived alone (40% vs. 31%). Using a weighted propensity score method, we found a modest decrease in risk of decline at Wave 2 for those with baseline modifications (risk difference = 3.1%). Respondents with a baseline residential modification were less likely to experience subsequent decline in functional ability (adjusted odds ratio = 0.88, 95% confidence interval = 0.79-0.97) after adjusting for quintile of propensity score in a survey-weighted regression model. IMPLICATIONS: Baseline modifications may be associated with reduced risk of decline among a nationally representative sample of older community-dwelling adults. Widespread adoption of residential modifications may reduce the overall population estimates of declin

Residential Modifications and Decline in Physical Function Among Community-Dwelling Older Ad

Purpose: The purpose of this study is to quantify the effect of residential modification on decreasing the risk of physical function decline in 2 years. Design: Cohort study using propensity scores method to control for baseline differences between individuals with residential modifications and those without residential modifications. Participants: Participants (N = 9,447) were from the Second Longitudinal Study on Aging, a nationally representative sample of the civilian noninstitutionalized population, aged 70 years and older in the United States at the time of baseline interview in 1994-1995. Methods: Participants self-reported residential modifications at baseline (e.g., railings, bathroom modifications). The decline in physical functioning was measured by comparing self-reported activities of daily living at baseline and at 2-year follow-up. Results: Compared with individuals without baseline modifications, a higher proportion of those with baseline modifications were aged 85 years and older (16% vs. 10%), used special aides (36% vs. 14%), and lived alone (40% vs. 31%). Using a weighted propensity score method, we found a modest decrease in risk of decline at Wave 2 for those with baseline modifications (risk difference = 3.1%). Respondents with a baseline residential modification were less likely to experience a subsequent decline in functional ability (adjusted odds ratio = 0.88, 95% confidence interval = 0.79-0.97) after adjusting for quintile of the propensity score in a survey-weighted regression model. Implications: Baseline modifications may be associated with reduced risk of decline among a nationally representative sample of older community-dwelling adults. Widespread adoption of residential modifications may reduce the overall population estimates of decline

Hospice and pain management in nursing home residents with cancer

Background: The prevalence of untreated pain in nursing home residents with cancer is unacceptably high. Hospice may increase the likelihood of receiving pain management at the end of life. Objectives: To estimate whether receipt of hospice in nursing homes increases the receipt of pain management for nursing home residents with cancer at the end of life. Methods: We conducted a cross-sectional study on a national sample of Medicare decedents who had cancer and were nursing home residents during the last 90 days of life in 2011–2012. We used the last Minimum Data Set (MDS) 3.0 assessment before death and the Medicare Beneficiary Summary File to measure hospice use, pain, and pain management at the last MDS assessment. We matched residents with cancer and in pain who received hospice care to residents in pain not receiving hospice care on nursing home facility and time from last MDS assessment to death. The primary outcomes were receipt of pharmacologic pain management including scheduled and PRN analgesics and non-pharmacologic pain management. Conditional logistic models were used to estimate the association between hospice use and pain management. Results: In matched analyses, untreated pain was uncommon (2.9% in hospice users and 5.6 in non-hospice users), though there was an absolute difference of 15.4% in scheduled analgesics use between hospice and non-hospice users (71.5% vs. 56.1%, respectively). Hospice use was associated with receipt of scheduled analgesics (adjusted Odds Ratio(aOR): 1.85, 95% Confidence Interval(CI):1.73–1.97), PRN medication (aOR: 1.31, 95% CI:1.20–1.43), and non-pharmacologic pain management (aOR: 1.18, 95% CI:1.11–1.26). Conclusions: Untreated pain at the end of life among nursing home residents with cancer was unusual. Hospice use was associated with increased pain management in nursing home residents with documented pain. Further work to examine the type and effectiveness of pain management strategies used is warranted

Post-Acute Care Setting, Facility Characteristics, and Post-Stroke Outcomes: A Systematic Review

OBJECTIVE: To synthesize research comparing post-stroke health outcomes between patients rehabilitated in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs). Secondly, to evaluate relationships between facility characteristics and outcomes. DATA SOURCES: PubMed and CINAHL searches spanned January 1, 1998 to October 6, 2016 and encompassed MeSH and free-text keywords for stroke, IRF/SNF, and study outcomes. Human and English limits were used. STUDY SELECTION: Observational and experimental studies examining outcomes of adult stroke patients rehabilitated in an IRF or SNF were eligible. Studies had to provide site of care comparisons and/or analyses incorporating facility-level characteristics and had to report \u3e 1 primary outcome (discharge setting, functional status, readmission, quality of life, all-cause mortality). Unpublished, single-center, descriptive, and non-US studies were excluded. Articles were reviewed by one author and when uncertain, discussion with study coauthors achieved consensus. Fourteen (0.3%) titles were included. DATA EXTRACTION: The types of data, time period, size, design, and primary outcomes were extracted. We also extracted two secondary outcomes (length of IRF/SNF stay, cost) when reported by included studies. Effect measures, modeling approaches, methods for confounding adjustment, and potential confounders were extracted. Data were abstracted by one author and the accuracy verified by a second reviewer. DATA SYNTHESIS: Two studies evaluating community discharge, one study evaluating predicted readmission probability, and 3 studies evaluating all-cause mortality favored IRFs over SNFs. Functional status comparisons were inconsistent. No studies evaluated quality of life. Two studies confirmed increased costs in the IRF versus SNF setting. Although substantial facility variation was described, few studies characterized sources of variation. CONCLUSIONS: The few studies comparing post-stroke outcomes indicated better outcomes (with greater costs) for patients in IRFs versus SNFs. Contemporary research on the role of the post-acute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform

Medicare Part D and Long-Term Care: A Systematic Review of Quantitative and Qualitative Evidence

BACKGROUND: In the largest overhaul to Medicare since its creation in 1965, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established Part D in 2006 to improve access to essential medication among disabled and older Americans. Despite previous evidence of a positive impact on the general Medicare population, Part D\u27s overall effects on long-term care (LTC) are unknown. OBJECTIVE: The purpose of this systematic review was to evaluate the literature regarding Part D\u27s impact on the LTC context, specifically costs to LTC residents, providers and payers; prescription drug coverage and utilization; and clinical and administrative outcomes. DATA SOURCES: Four electronic databases [PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Business Fulltext Elite and Science Citation Index Expanded], selected US government and non-profit websites, and bibliographies were searched for quantitative and qualitative studies characterizing Part D in the LTC context. Searches were limited to studies that may have been published between 1 January 2006 (date of Part D implementation) and 8 January 2013. STUDY SELECTION: Systematic searches identified 1,624 publications for a three-stage (title, abstract and full-text) review. Included publications were in English language; based in the US; assessed Part D-related outcomes; and included or were directly relevant to LTC residents or settings. News articles, reviews, opinion pieces, letters or commentaries; case reports or case series; simulation or modeling studies; and summaries that did not report original data were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS: A standardized form was used to abstract study type, study design, LTC setting, sources of data, method of data collection, time periods assessed, unit of observation, outcomes and results. Methodological quality was assessed using modified criteria specific to quantitative and qualitative studies. RESULTS: Eleven quantitative and eight qualitative studies met inclusion criteria. In the seven years since its implementation, Part D decreased out-of-pocket costs among enrolled nursing home residents and potentially increased costs borne by LTC facilities. Coverage of prescription drugs frequently used by older adults was adequate, except for certain drugs and alternative formulations of importance to LTC residents. The use of medications that raise safety concerns was decreased, but overall drug utilization may have been unaffected. Although there was uncertain impact on clinical outcomes, quantitative studies demonstrated evidence of unintended health consequences. Qualitative studies consistently revealed increased administrative burden among providers. LIMITATIONS: Empirical evidence of Part D\u27s LTC impact was sparse. Due to limitations in available types of data, quantitative studies were generically lacking in methodological rigor. Qualitative studies suffered from lack of clarity of reporting. As future studies use clinical Medicare data, study quality is expected to improve. CONCLUSION: Although LTC-specific policies continue to evolve, it appears that the prescription drug benefit may require further modifications to more effectively provide for LTC residents\u27 unique medication needs and improve their health outcomes. Adjustments may be needed for Part D to be more compatible with LTC prescription drug delivery processes

Pharmaceutical Pain Management among Older Adults with Cancer in Nursing Homes

Background: In the mid-1990s, 29.4% of nursing home (NH) residents with cancer suffered from daily pain, and among them 26% failed to receive analgesic medication. Improvements in cancer pain management in NHs have not been re-evaluated since the implementation of pain management quality indicators. Methods: We performed a cross-sectional study using nationwide data on NH resident health from the Minimum Data Set (version 2.0) linked to all-payer pharmacy dispensing records (February 2006–June 2007). Prevalence of pain (daily, less than daily, horrible/excruciating, moderate) and receipt of non-opioid and opioid analgesics were calculated. We used multinomial logistic regression to evaluate resident-level correlates of pain and binomial logistic regression to identify correlates of untreated pain. Results: 8,094 newly-admitted, Medicare-eligible residents had cancer. 65.6% had any pain (28.3% daily, 37.3% less than daily), among whom 13.5% had severe and 61.3% had moderate pain. Women, residents who were bedfast and those with compromised activities of daily living, depressed mood, indwelling catheter, or terminal prognosis were more likely to report pain. More than 17% of residents in daily pain (95% confidence interval [CI], 15.8–18.9%) and 14.2% with horrible/excruciating pain (95% CI, 11.7–16.8%) received no analgesics. Analgesic treatment was negatively associated with age \u3e85 (adjusted odds ratio [aOR]=0.67, 95% CI: 0.55–0.81 versus aged 65–74), impaired cognition (aOR=0.71, 95% CI: 0.61–0.82), presence of feeding tube (aOR=0.75, 95% CI: 0.58–0.97), and use of restraints (aOR=0.50, 95% CI: 0.31–0.81). Conclusion: Untreated pain is still common among NH residents with cancer, and persists despite pain management quality indicators

Triad of Suffering: Pain, Depression, and Anxiety among Newly Admitted Nursing Homes Residents

Introduction: Depression and anxiety disorders are prevalent among older adults, as is pain. These conditions are independently associated with reduced functioning and quality of life. Despite the frequent co-occurrence of all three of these disorders, little is known about the epidemiology and treatment of these disorders in nursing homes. The objectives of this study were to: 1) describe the prevalence of depression, anxiety disorders, and pain among newly admitted nursing home residents; and 2) describe the treatment of these disorders. Methods: We used national Minimum Data Set (MDS) version 3.0 data from 2011-2012. Federally-mandated for all residents living in Medicare/Medicaid-certified nursing facilities, the MDS is a comprehensive clinical assessment including \u3e 400 items on sociodemographics, mood and behavior, symptoms, pain, clinical diagnoses, and treatments. We identified residents with MDS assessments performed at admission between 2011-2012 who were 65 years of age or older; were non-comatose; were not admitted to a swing bed provider; did not have mental retardation or developmental delays; & were able to complete a pain assessment (n = 783,826). Results: At admission, 36% of residents (n = 283,050) had a documented active diagnosis of depression (other than bipolar disorder), anxiety disorder, or both. Having pain in the last 5 days was reported by 53% of residents. Rates of self-reported pain were similar across psychiatric disorders. 60-62% of residents reporting pain received a combination of pain management interventions. More than a third of residents did not receive any psychiatric treatment. Conclusions: Many nursing home residents experience pain, depression, and anxiety at admission. Pain management is common. An improved understanding of the relationships between pain, mental health, and analgesic use is necessary since older adults, particularly those in nursing homes, are routinely excluded from clinical trials despite being at high risk for adverse effects of analgesics and other treatments