Association of a Communication Training Program With Use of Antipsychotics in Nursing Homes

Importance: Off-label antipsychotic prescribing in nursing homes (NHs) is common and is associated with increased risk of mortality in older adults. Prior large-scale, controlled trials in the NH setting failed to show meaningful reductions in antipsychotic use. Objective: To quantify the influence of a large-scale communication training program on NH antipsychotic use called OASIS. Design, Setting, and Participants: This investigation was a quasi-experimental longitudinal study of NHs in Massachusetts enrolled in the OASIS intervention. Participants were residents living in NHs between March 1, 2011, and August 31, 2013. The data were analyzed from December 2015, to March 2016, and from November through December 2016. Exposures: The OASIS educational program targets all NH staff (direct care and nondirect care) using a train-the-trainer model. The program goals were to reframe challenging behaviors of residents with cognitive impairment as the communication of unmet needs, to train staff to anticipate resident needs, and to integrate resident strengths into daily care plans. Main Outcomes and Measures: This study used an interrupted time series model of facility-level prevalence of antipsychotic medication use, other psychotropic medication use (antidepressants, anxiolytics, and hypnotics), and behavioral disturbances to evaluate the intervention\u27s effectiveness in participating facilities compared with control NHs in Massachusetts and New York. The 18-month preintervention (baseline) period was compared with a 3-month training period, a 6-month implementation period, and a 3-month maintenance period. Results: This study included 93 NHs enrolled in the OASIS intervention (27 of which had a high prevalence of antipsychotic use) compared with 831 nonintervention NHs. Among OASIS facilities, prevalences of atypical antipsychotic prescribing were 34.1% at baseline and 26.5% at the study end (absolute reduction of 7.6% and relative reduction of 22.3%) compared with a drop of 22.7% to 18.8% in the comparison facilities (absolute reduction of 3.9% and relative reduction of 17.2%). In the OASIS implementation phase, NHs experienced a reduction in antipsychotic use prevalence among OASIS facilities (-1.20%; 95% CI, -1.85% to -0.09% per quarter) greater than that among non-OASIS facilities (-0.23%; 95% CI, -0.47% to 0.01% per quarter), resulting in a net OASIS influence of -0.97% (95% CI, -1.85% to -0.09%; P = .03). A difference in trend was not sustained in the maintenance phase (difference of 0.93%; 95% CI, -0.66% to 2.54%; P = .48). No increases in other psychotropic medication use or behavioral disturbances were observed. Conclusions and Relevance: Antipsychotic use prevalence declined during OASIS implementation of the intervention, but the decreases did not continue in the maintenance phase. Other psychotropic medication use and behavioral disturbances did not increase. This study adds evidence for nonpharmacological programs to treat behavioral and psychological symptoms of dementia

Lessons learned from frontline skilled nursing facility staff regarding COVID‐19 vaccine hesitancy

BackgroundPresently a median of 37.5% of the U.S. skilled nursing facility (SNF) workforce has been vaccinated for COVID‐19. It is essential to understand vaccine hesitancy among SNF workers to inform vaccine campaigns going forward.ObjectiveTo describe the concerns raised among healthcare workers and staff from SNFs during town hall meetings.DesignSixty‐three SNFs from four corporations were invited to send Opinion Leaders, outspoken staff from nursing, nurse aid, dietary, housekeeping or recreational therapy, to attend a 1‐h virtual town hall meeting. Meetings used a similar format where the moderator solicited concerns that the attendees themselves had or had heard from others in the facility about the COVID‐19 vaccine. Physicians and moderators used personal stories to address concerns and reaffirmed positive emotions.SettingTwenty‐six video town hall meetings with SNF staff.ParticipantsHealthcare workers and staff, with physicians serving as content experts.MeasurementQuestions and comments about the COVID‐19 vaccines noted by physicians.ResultsOne hundred and ninety three staff from 50 facilities participated in 26 meetings between December 30, 2020 and January 15, 2021. Most staff reported getting information about the vaccine from friends or social media. Concerns about how rapidly the vaccines were developed and side effects, including infertility or pregnancy related concerns, were frequently raised. There were no differences in concerns raised by discipline. Questions about returning to prior activities after being vaccinated were common and offered the opportunity to build on positive emotions to reduce vaccine hesitancy.ConclusionsMisinformation about the COVID‐19 vaccine was widespread among SNF staff. Sharing positive emotions and stories may be more effective than sharing data when attempting to reduce vaccine hesitancy in SNF staff.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/167807/1/jgs17136.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/167807/2/jgs17136_am.pd

Perspectives on Deprescribing in long-term care: qualitative findings from nurses, aides, residents, and proxies

Abstract Background Deprescribing initiatives in the long-term care (LTC) setting are often unsuccessful or not sustained. Prior research has considered how physicians and pharmacists feel about deprescribing, yet little is known about the perspectives of frontline nursing staff and residents. Our aim was to elicit perspectives from LTC nursing staff, patients, and proxies regarding their experiences and preferences for deprescribing in order to inform future deprescribing efforts in LTC. Methods This study was a qualitative analysis of interviews with nurses, nurse aides, a nurse practitioner, residents, and proxies (family member and/or responsible party) from three LTC facilities. The research team used semi-structured interviews. Guides were designed to inform an injury prevention intervention. Interviews were recorded and transcribed. A qualitative framework analysis was used to summarize themes related to deprescribing. The full study team reviewed the summary to identify actionable, clinical implications. Results Twenty-six interviews with 28 participants were completed, including 11 nurse aides, three residents, seven proxies, one nurse practitioner, and six nurses. Three themes emerged that were consistent across facilities: 1) build trust with team members, including residents and proxies; 2) identify motivating factors that lead to resident, proxy, nurse practitioner, and staff acceptance of deprescribing; 3) standardize supportive processes to encourage deprescribing. These themes suggest several actionable steps to improve deprescribing initiatives including: 1) tell stories about successful deprescribing, 2) provide deprescribing education to frontline staff, 3) align medication risk/benefit discussions with what matters most to the resident, 4) standardize deprescribing monitoring protocols, 5) standardize interprofessional team huddles and care plan meetings to include deprescribing conversations, and 6) strengthen non-pharmacologic treatment programs. Conclusions By interviewing LTC stakeholders, we identified three important themes regarding successful deprescribing: Trust, Motivating Factors, and Supportive Processes. These themes may translate into actionable steps for clinicians and researchers to improve and sustain person-centered deprescribing initiatives. Trial registration NCT0424218

Interruptions of once-daily thoracic radiotherapy do not correlate with outcomes in limited stage small cell lung cancer: analysis of CALGB phase III trial 9235

PURPOSE: Retrospective data suggests prolonging the time to complete thoracic radiotherapy (TRT) may negatively impact tumor control and survival in limited stage small cell lung cancer (LSCLC). We examined the association between TRT duration and outcomes on a prospective phase III study. MATERIAL AND METHODS: This review included 267 patients who received protocol TRT on a phase III CALGB LSCLC study assessing the addition of tamoxifen to standard chemo-radiotherapy. TRT, to a planned dose of 50Gy in 2Gy daily fractions, was initiated with the fourth chemotherapy cycle. TRT interruptions were mandated for hematologic toxicity (granulocytes\u3c1000/mm3 or platelets\u3c75,000/mm3) and esophageal toxicity (dysphagia necessitating intravenous hydration). RESULTS: TRT interruptions \u3e or =3 days occurred in 115 patients (43%), most frequently during the 4th week of TRT, and did not differ between treatment arms. Hematologic toxicity and esophageal toxicity were the most frequent indications for interrupting TRT. Variables including advanced age ( \u3e 70 years), gender, race, or radiotherapy treatment volume did not predict for TRT interruptions. Overall survival (OS) and local tumor control did not correlate with the administration of TRT interruptions or with TRT duration. CONCLUSION: Toxicity mandated interruptions of conventional dose, once-daily, TRT may not adversely affect outcomes for patients receiving TRT concurrent with chemotherapy (cycle 4) for LSCLC. The implications for accelerated or high dose TRT regimens are not clear

Methane Emissions from United States Natural Gas Gathering and Processing

New facility-level methane (CH₄) emissions measurements obtained from 114 natural gas gathering facilities and 16 processing plants in 13 U.S. states were combined with facility counts obtained from state and national databases in a Monte Carlo simulation to estimate CH₄ emissions from U.S. natural gas gathering and processing operations. Total annual CH₄ emissions of 2421 (+245/–237) Gg were estimated for all U.S. gathering and processing operations, which represents a CH₄ loss rate of 0.47% (±0.05%) when normalized by 2012 CH₄ production. Over 90% of those emissions were attributed to normal operation of gathering facilities (1697 +189/–185 Gg) and processing plants (506 +55/-52 Gg), with the balance attributed to gathering pipelines and processing plant routine maintenance and upsets. The median CH₄ emissions estimate for processing plants is a factor of 1.7 lower than the 2012 EPA Greenhouse Gas Inventory (GHGI) estimate, with the difference due largely to fewer reciprocating compressors, and a factor of 3.0 higher than that reported under the EPA Greenhouse Gas Reporting Program. Since gathering operations are currently embedded within the production segment of the EPA GHGI, direct comparison to our results is complicated. However, the study results suggest that CH₄ emissions from gathering are substantially higher than the current EPA GHGI estimate and are equivalent to 30% of the total net CH₄ emissions in the natural gas systems GHGI. Because CH₄ emissions from most gathering facilities are not reported under the current rule and not all source categories are reported for processing plants, the total CH₄ emissions from gathering and processing reported under the EPA GHGRP (180 Gg) represents only 14% of that tabulated in the EPA GHGI and 7% of that predicted from this study

Methane Emissions from United States Natural Gas Gathering and Processing

New facility-level methane (CH₄) emissions measurements obtained from 114 natural gas gathering facilities and 16 processing plants in 13 U.S. states were combined with facility counts obtained from state and national databases in a Monte Carlo simulation to estimate CH₄ emissions from U.S. natural gas gathering and processing operations. Total annual CH₄ emissions of 2421 (+245/–237) Gg were estimated for all U.S. gathering and processing operations, which represents a CH₄ loss rate of 0.47% (±0.05%) when normalized by 2012 CH₄ production. Over 90% of those emissions were attributed to normal operation of gathering facilities (1697 +189/–185 Gg) and processing plants (506 +55/-52 Gg), with the balance attributed to gathering pipelines and processing plant routine maintenance and upsets. The median CH₄ emissions estimate for processing plants is a factor of 1.7 lower than the 2012 EPA Greenhouse Gas Inventory (GHGI) estimate, with the difference due largely to fewer reciprocating compressors, and a factor of 3.0 higher than that reported under the EPA Greenhouse Gas Reporting Program. Since gathering operations are currently embedded within the production segment of the EPA GHGI, direct comparison to our results is complicated. However, the study results suggest that CH₄ emissions from gathering are substantially higher than the current EPA GHGI estimate and are equivalent to 30% of the total net CH₄ emissions in the natural gas systems GHGI. Because CH₄ emissions from most gathering facilities are not reported under the current rule and not all source categories are reported for processing plants, the total CH₄ emissions from gathering and processing reported under the EPA GHGRP (180 Gg) represents only 14% of that tabulated in the EPA GHGI and 7% of that predicted from this study