Bernard-Simon Leclerc

Fluoride in drinking water and osteosarcoma incidence rates in the continental United States among children and adolescents

INTRODUCTION It has been suggested that fluoride in drinking water may increase the risk of osteosarcoma in children and adolescents, although the evidence is inconclusive. We investigated the association between community water fluoridation (CWF) and osteosarcoma in childhood and adolescence in the continental U.S. METHODS We used the cumulative osteosarcoma incidence rate data from the CDC Wonder database for 1999-2006, categorized by age group, sex and states. States were categorized as low (≤30%) or high (≥85%) according to the percentage of the population receiving CWF between 1992 and 2006. Confidence intervals for the incidence rates were calculated using the Gamma distribution and the incidence rates were compared between groups using Poisson regression models. RESULTS We found no sex-specific statistical differences in the national incidence rates in the younger groups (5-9, 10-14), although 15-19 males were at higher risk to osteosarcoma than females in the same age group (p<0.001). Sex and age group specific incidence rates were similar in both CWF state categories. The higher incidence rates among 15-19 year old males vs females was not associated with the state fluoridation status. We also compared sex and age specific osteosarcoma incidence rates cumulated from 1973 to 2007 from the SEER 9 Cancer Registries for single age groups from 5 to 19. There were no statistical differences between sexes for 5-14 year old children although incidence rates for single age groups for 15-19 year old males were significantly higher than for females. CONCLUSION Our ecological analysis suggests that the water fluoridation status in the continental U.S. has no influence on osteosarcoma incidence rates during childhood and adolescence.

Relationship between home hazards and falling among community-dwelling seniors using home-care services

BACKGROUND Evidence linking home hazards to falls has not been well established. The evidence-based approach to fall-risk assessment in longitudinal studies becomes difficult because of exposures that change during follow-up. We conducted a cohort study to determine the prevalence of hazards and to resolve whether they are linked to the risk of falls among 959 seniors receiving home-care services. METHODS A home hazards assessment was completed at entry and every six months thereafter using a standardized form. The adjusted (for a number of confounding factors) relationship between home hazards and falls was estimated using a survival model taking into account updated time-varying exposures and multiple events. Falls leading to a medical consultation were examined as a secondary outcome, hypothesized as a measure of severity. FINDINGS Home environmental hazards were found in 91% of homes, with a mean of 3.3 risks per individual. The bathroom was the most common place for hazards. The presence of hazards was significantly associated with all falls and fall-related medical consultations, and showed relatively constant effects from one fall to another. IMPLICATIONS The current study is innovative in its approach and useful in its contribution to the understanding of the interaction between home environmental hazards and falls. Our results indicate that inattention to changes in exposure masks the statistical association between home hazards and falls. Each environmental hazard identified in the home increases the risk of falling by about 19%. These findings support the positive findings of trials that demonstrate the effectiveness of this home hazard reduction program, particularly for at-risk people.

Visual Acuity in Institutionalized Seniors With Moderate to Severe Dementia

OBJECTIVE The evaluation of visual acuity (VA) in cognitively impaired older individuals may be limited by a reduced ability to cooperate or communicate. The objective of this research was to assess VA in older institutionalized individuals with cognitive impairment, including severe dementia, using various acuity charts. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Three groups of 30 participants each were recruited: (1) young participants; (2) older participants with no history of cognitive or communication disorders; and (3) older participants with cognitive impairment, including severe dementia, residing in long term care facilities. The Mini-Mental State Examination was performed for each institutionalized subject. VA was measured using 6 validated charts [Snellen, Teller cards, Early Treatment Diabetic Retinopathy Study (ETDRS)-letters, -numbers, -Patty Pics, -Tumbling Es] presented in random order. Nonparametric tests were used to compare VA scores between charts, after Bonferroni-Holm corrections for multiple comparisons. RESULTS Participants in groups 1 and 2 responded to all charts. A large proportion of participants with dementia responded to all charts (n = 19), whereas only one did not respond to any chart. In group 3, VA charts with the lowest scores were the Teller cards (20/65) and Patty Pics (20/62), regardless of the level of dementia, whereas the highest VA scores were obtained with the Snellen (20/35) and ETDRS-letter (20/36) charts. Across all groups, the ETDRS-letter chart was the only one whose scores did not differ from those obtained with the standard Snellen chart. CONCLUSIONS Visual acuity can be measured, and should at least be attempted, in older cognitively impaired individuals having a reduced ability to communicate.

Short-term geriatric assessment units: 30 years later.

BackgroundThe increasing number of hospitalized elderly persons has greatly challenged decision makers to reorganize services so as to meet the needs of this clientele. Established progressively over the last 30 years, the short-term Geriatric Assessment Unit (GAU) is a specialized care program, now implemented in all the general hospital centres in Quebec. Within the scope of a broader reflection upon the appropriate care delivery for elderly patients in our demographic context, there is a need to revisit the role of GAU within the hospital and the continuum of care. The objective of this project is to describe the range of activities offered by Quebec GAU and the resources available to them.MethodsIn 2004, 64 managers of 71 GAU answered a mail questionnaire which included 119 items covering their units operation and resources in 2002-2003. The clinical and administrative characteristics of the clientele admitted during this period were obtained from the provincial database Med-Echo. The results were presented according to the geographical location of GAU, their size, their university academic affiliation, the composition of their medical staff, and their clinical care profile.ResultsOverall, GAU programs admitted 9% of all patients aged 65 years and older in the surveyed year. GAU patients presented one or more geriatric syndromes, including dementia. Based on their clientele, three distinct clinical care profiles of GAU were identified. Only 19% of GAU were focused on geriatric assessment and acute care management; 23% mainly offered rehabilitation care, and the others offered a mix of both types. Thus, there was a significant heterogeneity in GAUs operation.ConclusionsThe GAU is at the cutting edge of geriatric services in hospital centres. Given the scarcity of these resources, it would be appropriate to better target the clientele that may benefit from them. Standardizing and promoting GAUs primary role in acute care must be reinforced. In order to meet the needs of the frail elderly not admitted in GAU, alternative care models centered on prevention of functional decline must be applied throughout all hospital wards.

Quality-of-Care Processes in Geriatric Assessment Units: Principles, Practice, and Outcomes

OBJECTIVES To assess quality-of-care processes and to examine whether care processes are associated with short-term postdischarge outcomes in older vulnerable hospitalized patients. DESIGN Retrospective study. SETTING Forty-nine Geriatric Assessment Units. PARTICIPANTS Patients aged 65 and older who were admitted to a Geriatric Assessment Unit for a fall with trauma. MEASUREMENTS Three care processes (comprehensiveness, informational continuity, patient-centered care) assessed through chart audit; three-month postdischarge outcomes (emergency department visit, hospital readmission, and death) obtained from national databases. RESULTS A total of 934 hospitalization records were included. Mean comprehensiveness and informational continuity scores were 55% ± 12% and 42% ± 16%, respectively. Items related to geriatric global assessment (eg, functional autonomy) were particularly overlooked. Patient-centered care was poorly provided, with only 24% of hospitalization records showing evidence of advance care directives and at least one patient/family meeting with the physician to discuss clinical evolution. For the three care processes, a large variability among Geriatric Assessment Units was observed. Better comprehensiveness of care was associated with lowered short-term mortality (OR = 0.73, 95% CI = 0.55-0.96, P = .023), whereas higher scores on informational continuity was associated with fewer emergency department visits (OR = 0.91, 95% CI = 0.82-1.00, P = .046), hospital readmissions (OR = 0.84, 95% CI = 0.74-0.94, P = .003), and mortality (OR = 0.72, 95% CI = 0.59-0.88, P = .002). Patient-centered care was not associated with any of the postdischarge outcomes. CONCLUSION A large gap between geriatric care principles and practice in Geriatric Assessment Units has been observed. Our results show that improvement in care processes may be translated to decreased short-term health services use and mortality.

Quality of care assessment in geriatric evaluation and management units: construction of a chart review tool for a tracer condition

BackgroundThe number of elderly people requiring hospital care is growing, so, quality and assessment of care for elders are emerging and complex areas of research. Very few validated and reliable instruments exist for the assessment of quality of acute care in this field. This studys objective was to create such a tool for Geriatric Evaluation and Management Units (GEMUs).MethodsThe methodology involved a reliability and feasibility study of a retrospective chart review on 934 older inpatients admitted in 49 GEMUs during the year 2002–2003 for fall-related trauma as a tracer condition. Pertinent indicators for a chart abstraction tool, the Geriatric Care Tool (GCT), were developed and validated according to five dimensions: access to care, comprehensiveness, continuity of care, patient-centred care and appropriateness. Consensus methods were used to develop the content. Participants were experts representing eight main health care professions involved in GEMUs from 19 different sites. Items associated with high quality of care at each step of the multidisciplinary management of patients admitted due to falls were identified. The GCT was tested for intra- and inter-rater reliability using 30 medical charts reviewed by each of three independent and blinded trained nurses. Kappa and agreement measures between pairs of chart reviewers were computed on an item-by-item basis.ResultsThree quarters of 169 items identifying the process of care, from the case history to discharge planning, demonstrated good agreement (kappa greater than 0.40 and agreement over 70%). Indicators for the appropriateness of care showed less reliability.ConclusionContent validity and reliability results, as well as the feasibility of the process, suggest that the chart abstraction tool can gather standardized and pertinent clinical information for further evaluating quality of care in GEMU using admission due to falls as a tracer condition. However, the GCT should be evaluated in other models of acute geriatric units and new strategies should be developed to improve reliability of peer assessments in characterizing the quality of care for elderly patients with complex conditions.

Systematic review of vision‐related quality of life questionnaires for older institutionalised seniors with dementia

In view of our interest in helping older institutionalised adults with co‐existing visual and cognitive deficits, our objective was to review vision‐related quality of life (VRQoL) questionnaires developed for people with dementia.

Family Caregivers Perceptions of Palliative Care in Home and Unit: The Balance between Given and Received Support

Background: Family caregivers providing care to a terminally ill person are affected by the challenge of providing care at the endof-life stage. A palliative approach can differently mark the end-oflife experience for the caregiver, according to the kind of given and received social support. We searched to increase our understanding of what could influence the perceived experience of care by caregivers. Methods: This study focused on the experience of family caregivers, using a qualitative method, in regard to their perceptions of given and received social support from formal and informal sources while caring for a terminally ill person in different settings and trajectories of care, in home care or a specialized unit. Participants were 23 caregivers who cared for end-of-life patients at home and/ or in a specialized palliative care unit. Semi-structured face-to-face interviews were performed 3 to 6 months later and the data gathered were then qualitatively analyzed using an inductive grounded theory approach. Results: The results show that caring for a terminally ill person requires continuous balancing between given and received support to ease the caregiver’s experience. Analysis has identified the aspects affecting the balance between given and received social support and the ability of the caregiver to keep a positive perception of the lived experience. Conclusion: Finding revealed that family caregivers seem to cope better if they perceived sufficient social support during the caring period. These findings might be useful in the continuous improvement of training for different settings in palliative care and to focus on identifing the needs of caregivers.

Interprofessional meetings in geriatric assessment units: a matter of care organization

Abstract Inpatient geriatric assessment units (GAUs) exist in Quebec, Canada, to deliver comprehensive, integrated care to older vulnerable patients. Most cases should be discussed at interprofessional meetings (IMs), but research has shown this not to be so for 39% of GAU patients. Consequently, a study was undertaken to (1) describe GAU team composition and (2) identify GAU and patient characteristics associated with case discussion at IMs at least once during a patient’s stay. To this end, 877 hospitalization records from 44 GAUs were reviewed. Results showed most teams were composed of attending physicians, nurses, physical and occupational therapists, dietitians and social workers; 66% included clinical pharmacists and 43% liaison nurses. Multilevel modeling showed longer length of stay to be the strongest predictor of case discussion at an IM. Case discussion was also more likely for patients admitted via in- or inter-hospital transfer rather than via the emergency department, if the GAU included a liaison nurse, and if the GAU was not located in an urban area. In summary, case discussion at an IM depended more on how and where a patient was admitted than on the patient characteristics per se, suggesting that this is a matter of care organization.

Predictors of quality-of-care processes in geriatric assessment units: toward a better organizational framework.

OBJECTIVES To identify the structural and patient characteristics associated with better care processes in older vulnerable hospitalized patients. DESIGN Retrospective study. SETTING Forty-four Geriatric Assessment Units (GAU). PARTICIPANTS Patients aged 65 and older who were admitted to a GAU for a fall with trauma. MEASUREMENTS Three care processes (comprehensiveness, informational continuity, completion of advance health care directives) assessed through chart audit; 14 patient- and 23 GAU-related characteristics obtained from hospitalization records, national databases, and GAU managers. RESULTS A total of 877 hospitalization records were included. Final models were based on multilevel modeling using stepwise variable selection. Strongest predictors of better comprehensiveness were longer hospital length of stay (LOS), higher clinical complexity (eg, higher mortality risk), and having a geriatrician as attending physician. Comprehensiveness score increased sharply up to 3 weeks LOS and then tended to plateau. Better informational continuity was associated with more comprehensive care, higher risk of mortality, acute rather than rehabilitation care, communication with community health care professionals within 48 hours after admission, and a target LOS of 3 weeks or longer. The completion of advance directives was more likely in the presence of advanced age, higher risk of mortality, cognitive impairment, discharge to another care facility, longer LOS, university-affiliated institution, and nonurban location. CONCLUSION In GAUs, quality-of-care processes are related to both structural and patient characteristics. Our results pointed toward an organizational framework that may help to streamline the geriatric units and better use resources, notably by narrowing the admission criteria, targeting a proper LOS, improving communication with community organizations, and making systematic completion of advance directives.