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Risk of Dementia Diagnosis After Injurious Falls in Older Adults
No full textImportance: Emerging evidence suggests that mild cognitive impairment, which is a precursor to Alzheimer disease and related dementias (ADRD), places older adults at increased risk for falls. However, the risk that an older adult develops dementia after experiencing a fall is unknown.
Objective: To determine the risk of new ADRD diagnosis after a fall in older adults.
Design, setting, and participants: This retrospective cohort study examined Medicare Fee-for-Service data from 2014 to 2015, with follow-up data available for at least 1 year after the index encounter. Participants included adults aged 66 years and older who experienced a traumatic injury that resulted in an emergency department (ED) or inpatient encounter and did not have a preexisting diagnosis of dementia. Data analysis was performed from August 2023 to July 2024.
Exposures: Experiencing a fall compared with other mechanisms of injury, defined by International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 external cause of injury codes.
Main outcomes and measures: The hazard of new ADRD diagnosis within 1 year of a fall, assessed by performing a Cox multivariable competing risk model that controlled for potential confounders while accounting for the competing risk of death.
Results: The study included 2 453 655 older adult patients who experienced a traumatic injury; 1 522 656 (62.1%) were female; 124 396 (5.1%) were Black and 2 232 102 (91.0%) were White; and the mean (SD) age was 78.1 (8.1) years. The mechanism of injury was a fall in 1 228 847 incidents (50.1%). ADRD was more frequently diagnosed within 1 year of a fall compared with other injury mechanisms (10.6% [129 910 of 1 228 847] vs 6.1% [74 799 of 1 224 808]; P \u3c .001). The unadjusted hazard ratio (HR) of incident dementia diagnosis after a fall was 1.63 (95% CI, 1.61-1.64; P \u3c .001). On multivariable Cox competing risk analysis, falling was independently associated with an increased risk of dementia diagnosis among older adults (HR, 1.21 [95% CI, 1.20-1.21]; P \u3c .001) after controlling for patient demographics, medical comorbidities, and injury characteristics, while accounting for the competing risk of death. Among the subset of older adults without a recent skilled nursing facility admission, the HR was 1.27 (95% CI, 1.26-1.28; P \u3c .001).
Conclusions and relevance: In this cohort study, new ADRD diagnoses were more common after falls compared with other mechanisms of injury, with 10.6% of older adults being diagnosed with ADRD in the first year after a fall. To improve the early identification of ADRD, this study\u27s findings suggest support for the implementation of cognitive screening in older adults who experience an injurious fall that results in an ED visit or hospital admission
Syringe Access, Syringe Sharing, and Perceptions of HCV: A Qualitative Study Exploring the HCV Risk Environment in Rural Northern New England, United States
No full textThe ongoing hepatitis C virus (HCV) epidemic in the United States disproportionately affects rural people who inject drugs (PWID). This study explores the HCV risk environment in rural northern New England by examining PWID experiences and perceptions of HCV and injection equipment-sharing practices. We performed a thematic analysis on semi-structured interviews conducted with 21 adults with a history of injection drug use from rural New Hampshire, Vermont, and Massachusetts between April 2018 and August 2019. Salient themes included: (1) limited and varied access to sterile syringe sources; (2) syringe scarcity contributing to the use of informal syringe sources (e.g., secondary syringe exchange or syringe sellers who purchased syringes from out-of-state pharmacies); (3) syringe scarcity contributing to syringe sharing; (4) linkages among decisions about syringe sharing and perceptions of HCV risk, HCV status, and interpersonal trust; and (5) confusion and misconceptions about HCV, including difficulty learning one\u27s HCV status, inadequate HCV education, and misconceptions regarding HCV transmission and treatment. Efforts to prevent and eliminate HCV among rural PWID should expand syringe access, increase awareness of HCV as a serious but preventable risk, and acknowledge social connections as potential influences on syringe access and syringe-sharing decisions.
Keywords: harm reduction; hepatitis C virus; injection drug use; risk environment; rural; syringe sharing
Caring Moments for Healthcare Staff on an Acute Care Floor
Get PDFhttps://scholarlycommons.libraryinfo.bhs.org/nurs_presentations2024/1013/thumbnail.jp
Acts of Random Kindness in a Level 1 Trauma Center
Get PDFhttps://scholarlycommons.libraryinfo.bhs.org/nurs_presentations2024/1012/thumbnail.jp
Improving Pediatric Vascular Access: From Data Collection to Solution Implementation Purpose
Get PDFhttps://scholarlycommons.libraryinfo.bhs.org/nurs_presentations2024/1003/thumbnail.jp
We don\u27t get that information right back to us unless it\u27s a full-blown cancer : Challenges coordinating lung cancer screening across healthcare systems
No full textObjective: To examine how lung cancer screening (LCS) is coordinated across healthcare systems, specifically Veterans Affairs (VA) and non-VA settings.
Data sources and study setting: We conducted primary qualitative data collection in six VA medical centers with established LCS programs from November 2020 to November 2021.
Study design and data collection methods: Semi-structured interviews were conducted with 48 primary care providers, LCS program coordinators and directors, and pulmonologists. Thematic analysis examined spontaneously raised narratives related to initiating and coordinating LCS for Veterans screened in non-VA settings. We mapped coordination challenges to each step of the LCS care continuum.
Principal findings: While non-VA options increased access to LCS for Veterans, VA medical centers lacked clear processes for initiating LCS referrals and tracking Veterans across the LCS continuum when screening occurred in non-VA settings. The responsibility of coordinating LCS with community providers often fell to VA primary care providers rather than LCS programs. Gaps in communication and data transfer contributed to delayed evaluation of potentially cancerous nodules post-screening, raising concerns about compromised care quality when LCS was shared with non-VA settings.
Conclusions: While policies expanding LCS for Veterans in non-VA settings increase access, lack of consistent processes to initiate referrals, obtain results, and promote timely downstream evaluation fragmented care and delayed evaluation of concerning nodules. These unintended consequences highlight a need to address cross-system coordination challenges. Strategies to better coordinate LCS between VA and non-VA settings are essential to achieve high quality LCS and prevent Veterans from falling through the cracks.
Keywords: Veterans; care coordination; health systems; lung cancer screening; patient‐centered care; primary care; qualitative research
Facilitators of and barriers to buprenorphine initiation in the emergency department: a scoping review
No full textBuprenorphine initiation in the Emergency Department (ED) has been hailed as an evidence-based strategy to mitigate the opioid overdose crisis, but its implementation has been limited. This scoping review synthesizes barriers and facilitators to buprenorphine initiation in the ED, and uses the Consolidated Framework for Implementation Research and a critical lens to analyze the literature. Results demonstrate an immense effort across the U.S. and Canada to implement ED-initiated buprenorphine. Facilitators include multidisciplinary addiction teams and co-located, low-barrier, harm reduction-informed services to support transitions. Barriers include a failure to address structural stigma, client complexity, and an increasingly toxic drug supply. The literature also misses the opportunity to include the perspectives of service users, health administrators, and learners. Increased coordination of implementation efforts, and a shift to equitable and inclusive opioid agonist therapy initiation pathways are needed across the U.S. and Canada.
Keywords: Buprenorphine; Emergency department; Implementation; Opioid use disorder; Scoping review
Affordable Care Act\u27s Preventive Services Coverage Mandate and Receipt of Fluoride Varnish
No full textBackground and objectives: The Affordable Care Act required private insurers to cover a set of recommended preventive services without cost-sharing. This included coverage of fluoride varnish (FV) applications without cost-sharing for children aged 1 through 5 during medical visits, an evidence-based treatment that prevents tooth decay. We examined if this coverage mandate was associated with more young children receiving FV.
Methods: Using the Massachusetts All-Payer Claims Database (2014-2018), we examined the likelihood that a privately insured child received FV during a medical visit in a month. We used a difference-in-differences approach, comparing those included in the coverage mandate (aged 1-5) to those excluded from the mandate (aged 6-9), before and after the mandate was enacted (January 2015). We repeated analyses in children with Medicaid because this mandate may have had spillover effects for this population.
Results: Among children aged 1 through 5 years with private insurance, 1-year postmandate the probability of FV receipt in a month increased 0.16 percentage points more relative to December 2014 (premandate) compared with the change among children aged 6 to 9 years (P \u3c .001; 95% confidence interval = 0.1-0.22). When examining spillover to children with Medicaid, the mandate was not associated with a significant increase in the probability of monthly FV receipt 1-year postmandate.
Conclusions: This Affordable Care Act mandate requiring coverage of FV without cost-sharing was associated with higher rates of young children receiving FV in medical settings, with the largest result observed among children with private insurance
Updates in Treatment of HER2-positive Metastatic Breast Cancer
No full textThe therapeutic landscape for HER2-positive metastatic breast cancer has exploded in the last two decades following the initial advent of trastuzumab, a monoclonal antibody. While the first line treatment has remained a combination of dual HER2 blockade with taxane chemotherapy, we now have several exciting options in the second line and beyond. The introduction of antibody-drug conjugates, in specific trastuzumab deruxtecan, has resulted in the best progression-free survival among patients with this subtype of breast cancer. Given the excellent outcomes of these drugs, clinical trials are now evaluating the role of ADCs in the front-line setting in previously untreated patients. In addition, there are also clinical trials evaluating the role of other targets in patients with HER2-positive cancers, including PI3KCA mutations, PD-L1 and CDK4/6. Given the predilection for brain metastases in this population, there is enthusiasm to identify the optimal combination of effective treatments. Tucatinib, capecitabine, and trastuzumab combination represent one such promising strategy. With the increasing longevity of these patients, important clinical questions include optimal treatment sequencing, the role of de-escalation of treatment in excellent responders, and the associated financial toxicity. Despite the aggressive nature of this subtype of breast cancer, the outcomes continue to improve for these patients with the evolving treatments.
Keywords: Antibody-drug conjugate; Breast cancer; HER2 positive breast cancer; Metastatic breast cancer; Trastuzumab
Reducing Door-to-Balloon Time Using EMS-Initiated App-Based Communication
No full textBackground: Reducing door-to-balloon (D2B) time for ST-segment elevation myocardial infarction (STEMI) has been shown to improve outcomes. Delays still occur due to various factors such as time to laboratory activation and diagnostic clarification in equivocal cases. We propose that early communication through a mobile application (app) between emergency medical services (EMS) and in-hospital providers can reduce EMS-to-balloon time and provide coordinated care to impact D2B time.
Methods: The General Devices e-Bridge mobile app, which allows real-time communication and data transmission between EMS providers and the cardiac catheterization laboratory and emergency department staff, was implemented on May 14, 2019. A single-center, retrospective observational study was conducted on 795 STEMI activations undergoing emergent coronary angiography between January 2017 and July 2020. After exclusions, EMS transmissions of 428 cases were analyzed, of which 132 used the app.
Results: Implementation of e-Bridge significantly reduced D2B time by 7.2 minutes (P = .005) and emergency department board time by 4.41 minutes (P = .01). First medical contact to balloon (FMC2B) time trended toward reduction but was not statistically significant. The app did not significantly reduce D2B or FMC2B time during the day shift but significantly improved these metrics during the night shift.
Conclusions: Implementation of app-based communication between EMS and in-hospital providers resulted in statistically significant reductions in D2B time at our institution. This approach holds promise in improving the timely management of STEMI patients, particularly during the night shift.
Keywords: ST-segment elevation myocardial infarction; app; door-to-balloon time; first medical contact to balloon time