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Colon-Emeric C.,Duke University | Colon-Emeric C.,Durham Geriatric Research Education and Clinical Center | Pieper C.F.,Duke University | Grubber J.,Durham Health Services Research and Development Center | And 9 more authors.
Bone | Year: 2015

Purpose: With ethical requirements to the enrollment of lower risk subjects, osteoporosis trials are underpowered to detect reduction in hip fractures. Different skeletal sites have different levels of fracture risk and response to treatment. We sought to identify fracture sites which cluster with hip fracture at higher than expected frequency; if these sites respond to treatment similarly, then a composite fracture endpoint could provide a better estimate of hip fracture reduction. Methods: Cohort study using Veterans Affairs and Medicare administrative data. Male Veterans (n. = 5,036,536) aged 50-99. years receiving VA primary care between 1999 and 2009 were included. Fractures were ascertained using ICD9 and CPT codes and classified by skeletal site. Pearson correlation coefficients, logistic regression and kappa statistics were used to describe the correlation between each fracture type and hip fracture within individuals, without regard to the timing of the events. Results: 595,579 (11.8%) men suffered 1 or more fractures and 179,597 (3.6%) suffered 2 or more fractures during the time under study. Of those with one or more fractures, the rib was the most common site (29%), followed by spine (22%), hip (21%) and femur (20%). The fracture types most highly correlated with hip fracture were pelvic/acetabular (Pearson correlation coefficient 0.25, p. <. 0.0001), femur (0.15, p. <. 0.0001), and shoulder (0.11, p. <. 0.0001). Conclusions: Pelvic, acetabular, femur, and shoulder fractures cluster with hip fractures within individuals at greater than expected frequency. If we observe similar treatment risk reductions within that cluster, subsequent trials could consider the use of a composite endpoint to better estimate hip fracture risk. © 2015 . Source


Colon-Emeric C.S.,Duke University | Colon-Emeric C.S.,Durham Geriatric Research Education and Clinical Center | Pinheiro S.O.,Duke University | Anderson R.A.,Duke University | And 8 more authors.
Gerontologist | Year: 2014

Purpose of the Study: The CONNECT intervention is designed to improve staff connections, communication, and use of multiple perspectives for problem solving. This analysis compared staff descriptions of the learning climate, use of social constructivist learning processes, and outcomes in nursing facilities receiving CONNECT with facilities receiving a falls education program alone. Design and Methods: Qualitative evaluation of a randomized controlled trial was done using a focus group design. Facilities (n = 8) were randomized to a falls education program alone (control) or CONNECT followed by FALLS (intervention). A total of 77 staff participated in 16 focus groups using a structured interview protocol. Transcripts were analyzed using framework analysis, and summaries for each domain were compared between intervention and control facilities. Results: Notable differences in descriptions of the learning climate included greater learner empowerment, appreciation of the role of all disciplines, and seeking diverse viewpoints in the intervention group. Greater use of social constructivist learning processes was evidenced by the intervention group as they described greater identification of communication weaknesses, improvement in communication frequency and quality, and use of sense-making by seeking out multiple perspectives to better understand and act on information. Intervention group participants reported outcomes including more creative fall prevention plans, a more respectful work environment, and improved relationships with coworkers. No substantial difference between groups was identified in safety culture, shared responsibility, and self-reported knowledge about falls. Implications: CONNECT appears to enhance the use of social constructivist learning processes among nursing home staff. The impact of CONNECT on clinical outcomes requires further study. © 2013 The Author. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. Source


Lee R.H.,Durham Geriatric Research Education and Clinical Center | Lee R.H.,Duke University | Lyles K.W.,Durham Geriatric Research Education and Clinical Center | Lyles K.W.,Carolinas Center for Medical Excellence | And 5 more authors.
Calcified Tissue International | Year: 2014

Fewer than 24 % of Veterans received appropriate evaluation and/or treatment for osteoporosis within 6 months of an index fracture. An electronic consult (E-consult) service was implemented at three Veterans Affairs Medical Centers to facilitate the identification of and recommend management for patients with recent fracture. The E-consult service used clinical encounter data based on ICD9 diagnosis codes to prospectively identify patients with potential osteoporotic fractures. Eligible patients' medical records were reviewed by a metabolic bone specialist, and an E-consult note was sent to the patient's primary provider with specific recommendations for further management. Recommendations were initiated at the provider's discretion. Between 2011 and 2013, the E-consult service identified 444 eligible patients with a low-trauma fracture who were not already on treatment. One hundred twenty-nine (29.1 %) consults recommended immediate bisphosphonate treatment, and 258 (58.1 %) recommended bone density assessments. Primary providers responded by prescribing bisphosphonates in 74 patients (57.4 %) and by ordering bone density testing in 183 (70.9 %) patients. At the facility level, prior to implementation of the E-consult service, the rate of osteoporosis treatment following a fracture was 4.8 % for bisphosphonates and 21.3 % for calcium/vitamin D. After implementation, the treatment rate increased to 7.3 % for bisphosphonates (p = 0.02) and 35.2 % for calcium/vitamin D (p < 0.01). While feasible and relatively low-cost, an E-consult service modestly improved the rate of osteoporosis treatment among patients with a recent fracture. These results suggest that a program with direct patient interaction is probably required to substantially improve treatment rates. © 2014 Springer Science+Business Media. Source


Colon-Emeric C.,Duke University | Colon-Emeric C.,Durham Geriatric Research Education and Clinical Center | Toles M.,University of North Carolina at Chapel Hill | Cary M.P.,Duke University | And 8 more authors.
Implementation Science | Year: 2016

Background: Little is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC. Methods: In eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports. Results: Staff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using "train the trainer" approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability. Conclusions: When designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability. Trial registration: ClinicalTrial.gov, NCT00636675. © 2016 Colon-Emeric et al. Source

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