JULIE STUTZBACH
PT, DPT/PhD Trainee, Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA

Following a hospitalization and skilled nursing facility (SNF) stay, patients are often unprepared for the transition to home, as evidenced by enduring deficits in physical function and continued dependence for activities of daily living (ADLs) at time of discharge. 1) Our previous research has shown that just days before discharge, patients in SNFs took only 916 steps per day and were sitting or lying down 87% of their waking hours. 2) To put this finding into context: participants took far fewer than the ~2,500 steps per day considered basal activity (i.e., the minimum requirement to perform activities of daily living) were ~85% more sedentary than community-dwelling older adults. 3) To combat this pressing problem, we designed High-Intensity Rehabilitation plus Mobility (HeRo), a pilot pragmatic intervention to improve mobility and physical function while in the SNF.

Older adults (veterans) admitted to a single SNF following a hospitalization.

A mobility coach with certified nursing assistant credentials will deliver a structured mobility program to complement the progressive rehabilitation intervention that has been successfully implemented at the SNF facility. We will use a pragmatic, pre/post-test design to compare 2 historical cohorts (usual care, progressive rehabilitation alone) to HeRo (progressive rehabilitation coupled with structured mobility). Implementation will be iteratively developed and refined in collaboration with patients and SNF staff to increase adoption and utilization of the intervention. Qualitative interviews with patients and focus groups with providers will complement quantitative measures of effectiveness and implementation in a convergent, embedded mixed-methods design. Program implementation will be evaluated using the Consolidated Framework for Implementation Research4 and the RE-AIM Framework.5 Percent of patients admitted to the SNF who receive the intervention will determine reach. Effectiveness will be measured based on patient-centered outcomes including changes in gait speed, physical function, and physical activity. Focus groups, conducted at regular intervals with rehabilitation and nursing staff throughout the project, will explore how HeRo is integrated into daily practice as key indicators of adoption and potential for maintenance/sustainability. Direct observations of treatment fidelity sessions, documentation audits, and step count goal adherence will serve as indicators of implementation.

KATE MAGID
Health Science Specialist, Rocky Mountain Regional Veterans Affairs Medical Center

At the 2019 AMDA-The Society for Post-acute and Long-term Care Medicine symposium, researchers discussed the implementation of pragmatic trials in nursing homes. Relatively few pragmatic trials have been conducted in nursing homes. In this abstract, we review the extent to which the design and implementation of trials presented at the AMDA symposium were pragmatic with a goal of describing approaches to improve pragmatic nursing home research study design.

All trials were conducted in nursing homes, with sample sizes ranging from 12- 175 homes.1-6 Trials were conducted Europe and the United States. Participants varied by study and included nursing home residents, nursing home staff, and caregivers.

We used the Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) criteria to rate the pragmatic nature of the trials.7-8 Given that these trials were conducted at the level of the nursing home, reviewers rated recruitment and eligibility for nursing homes and residents separately. Subsequently, the reviewers discussed ratings and came to consensus. A PRECIS wheel was constructed for each trial to visually represent where the trial aligned on the explanatory-pragmatic continuum.

Figure 1 shows the PRECIS-2 wheels summarizing the pragmatic nature of the trials. Using PRECIS-2 criteria, the domains identified as most pragmatic across the trials were setting, primary outcome, and primary analysis. All studies were conducted in nursing homes that resembled usual care, collected primary outcomes relevant to participants, and almost all conducted an intention-to-treat analysis. In contrast, organization, nursing home recruitment, and nursing home eligibility were the least pragmatic. Several trials hired staff for intervention delivery or evaluation, implemented trainings, or provided resources beyond what is available in usual care, thus making the organization domain more explanatory. The eligibility criteria and recruitment for nursing homes were less pragmatic due to excluding homes based on; resident census, location, existing interventions and recruiting homes through advertisements or mailings. Four trials required residents or their legal guardian to provide informed consent to participate, making resident recruitment less pragmatic.

The application of PRECIS-2 criteria to the trials presented at the AMDA symposium suggests that the implementation of pragmatic trials in nursing homes have pragmatic and explanatory components. Future studies should explore how requiring residents to provide consent might lead to participants not being fully representative of the usual care population, especially given the prevalence of dementia in nursing homes. To better suit cluster pragmatic trials, researchers should rate the eligibility and recruitment of facilities and participants separately.

NAYANJOT KAUR RAI
Research Associate, University of Colorado School of Dental Medicine and Clinics

Tooth loss is a major contributing factor to oral health quality of life. Retaining at least 20 natural teeth is essential to maintain functional and aesthetic dentition throughout life. Tooth loss has been linked to some systemic diseases including, cardiovascular diseases (CVD) and diabetes and self-reported poor health status. We aim to evaluate the association of systemic health factors, including CVD, diabetes and tobacco use with tooth loss in patients visiting the University of Colorado School of Dental Medicine (SDM) clinics over four years. Also, we aim to analyze the trends in this association for the four consecutive years, 2017, 2018, 2019, and 2020.

Data was collected through mining the electronic health records (EHRs) by the firstyear dental students and third-year advanced degree international dental students and 2709 current patients were included (≥55 years of age). The EHRs were reviewed for age, gender, ethnicity, self-reported systemic diseases including, CVD, diabetes, and tobacco use and the number of natural teeth present in the oral cavity(<20: yes/no), which was chosen as the outcome of interest. Univariate and multivariate logistic regression analysis was performed to test the association between patients having <20 natural teeth and self-reported systemic diseases. Also, trends in the odds of having <20 teeth and percentage of <20 teeth in the oral cavity varying by reported systemic health factors were analyzed.

Of the 2709 patients, 37% had <20 natural teeth. The odds of having <20 teeth were higher in patients who reported having CVD (OR=1.3, 95% CI=1.1, 1.5, p=0.0007) and diabetes (OR=1.6, 95% CI=1.4, 2.0, p<0.0001) compared to patients who did not report CVD and diabetes respectively. Similarly, the odds of having <20 teeth were found to be more than two times greater in patients reporting tobacco use (OR=2.4, 95% CI=1.8, 3.0, p=<0.0001) compared to patients who never used tobacco. The trends analysis results demonstrated an increase in the odds of having <20 teeth from the years 2017 to 2019 in the adults who reported having diabetes followed by a decrease in 2020 (Figure 1). The odds of having <20 teeth increased in adults reporting CVD over the four years (Figure 1a). An overall increasing trend in the odds of having <20 teeth was also seen in adults reporting tobacco use.

The results have shown that patients reporting CVD, diabetes, and tobacco use are more likely to have tooth loss, and the odds have increased since 2017. The results indicate the need for educational programs to educate the SDM patients and students. The knowledge gained can lead to the design and implementation of evidence-based interventions at the school and community levels, thereby benefiting the overall health of the population.