Background: Little is known about health or service use outcomes for residents of Canadian assisted living facilities. Our objectives were to estimate the incidence of admission to hospital over 1 year for residents of designated (i.e., publicly funded) assisted living (DAL) facilities in Alberta, to compare this rate with the rate among residents of long-term care facilities, and to identify individual and facility predictors of hospital admission for DAL residents.
Methods: Participants were 1066 DAL residents (mean age ± standard deviation 84.9 ± 7.3 years) and 976 long-term care residents (85.4 ± 7.6 years) from the Alberta Continuing Care Epidemiological Studies (ACCES). Research nurses completed a standardized comprehensive assessment for each resident and interviewed family caregivers at baseline (2006 to 2008) and 1 year later. We used standardized interviews with administrators to generate facility-level data. We determined hospital admissions through linkage with the Alberta Inpatient Discharge Abstract Database. We used multivariable Cox proportional hazards models to identify predictors of hospital admission.
Results: The cumulative annual incidence of hospital admission was 38.9% (95% confidence interval [CI] 35.9%–41.9%) for DAL residents and 13.7% (95% CI 11.5%–15.8%) for long-term care residents. The risk of hospital admission was significantly greater for DAL residents with greater health instability, fatigue, medication use (11 or more medications), and 2 or more hospital admissions in the preceding year. The risk of hospital admission was also significantly higher for residents from DAL facilities with a smaller number of spaces, no licensed practical and/or registered nurses on site (or on site less than 24 hours a day, 7 days a week), no chain affiliation, and from select health regions.
Interpretation: The incidence of hospital admission was about 3 times higher among DAL residents than among long-term care residents, and the risk of hospital admission was associated with a number of potentially modifiable factors. These findings raise questions about the complement of services and staffing required within assisted living facilities and the potential impact on acute care of the shift from long-term care to assisted living for the facility-based care of vulnerable older people.
Recently there has been a lot of discussion on the medical library email listserv about the closure of another hospital library. Also in the news the CBC reported on the reprehensible state of their Health Canada library.
“Health Canada scientists are so concerned about losing access to their research library that they’re finding workarounds, with one squirrelling away journals and books in his basement for colleagues to consult.”
Not only are the collections missed by researchers but the librarians as well. Multiple researchers commented to the CBC on how important the librarians are to their research.
“My staff can do so much in sort of Googling around and trying to find this and that or stuff that may come into us. But being able to use the experts and to get their assistance makes a world of difference.”
Like the cuts made to hospital libraries, Health Canada states the cuts were made to save money. However there is a question as to whether those cuts indeed saved Health Canada any money. The CBC reports, “One of the stated goals of Health Canada’s contracting out of library services was to save money. According to the report, though, the new arrangement is more expensive.”
I have seen this happen in American hospitals that cut libraries AND American hospitals that don’t understand how to work with their librarians. A hospital cuts the library believing it is a way to save money. They often end up licensing duplicate online databases, journals, or delivery services. Fail to understand the nuances of negotiating library resources and end up with a poor deal. They fail to to get a decent ROI because they haven’t properly supported and integrated the resource into the system. Why pay thousands of dollars for an online journal that nobody knows exists because you didn’t set up the IP addresses and just handed out the username and password to a few physicians that asked? Another favorite of mine is a department buying a database for several thousand dollars, hoarding it among their employees in their department and then wondering why it was only used once a month.
The discussion on the medlibs listserv seemed to center around the question about what can be done about the situation and who should be doing it. What can individual librarians do and what should MLA be doing to get hospitals, administrations, governing and standards organizations to keep libraries in hospitals. Several people wrote that MLA should be doing more for hospital librarians and work to get the library back in the JCAHO standards or other accreditation organizations.
First I want to say that any medical librarian that believes the our salvation lies with getting JCAHO to reinstate the library as a requirement in hospitals is waiting for something that will never happen. JCAHO has moved on. It is a dead issue. It isn’t even going to be re-animated as zombie issue. It is dead, dead.
So now that we have cleared the air of the JCAHO thing….
I will bring up the issue that some librarians think MLA should be doing more to ensure our survival. Let me just say MLA staff (all 16 of them) are doing as much as the cany for the MLA members including advocating for them. The MLA President and Board are doing as much as they can too. However it is unfair to compare the advocating clout of ALA (which has a staff of over 300 and over 56,000 members) to that of MLA.
The only way I see medical librarians continuing on is to work together to get our message out. As many said on the listserv, medical librarians are too often preaching to the choir about our value and benefit. We need to take our message out to our patrons. Not only do we need to do this locally but nationally. As much as I am in favor of our medical library journals, we need to stop publishing about the value of library services in them and start publishing those kind of studies in our patrons’ journals which is what they read. Our patrons don’t read our professional journals. We need to attend and present at their meetings.
One librarian noted that publishing articles and attending their meetings is a little lofty of a goal for the part time librarians who are just struggling. I get it, you don’t have a lot time and some of that can be difficult. But we aren’t asking everybody to do everything. Work to your strengths. I am not good at research but I am good at social media and I am think of ways to get our word out via social media. (BTW at the suggestion of a person on the list, I have already tweeted Dr. Besser MLA’s 2013 speaker about the plight of medical libraries. It isn’t perfect but it is a start somewhere.) (*update* Dr. Besser responded and retweeted my message to his 33,000 followers. It is a baby step, but you have to take steps before you walk.)
Just because you are part time doesn’t mean you can’t do something when you aren’t in the library and you are at home. I am a working mother of 3 young children. My work on my blog, tweeting on #medlibs, writing journal articles, teaching MLA CE classes, and some of my work on the MLA Board often is done during my PERSONAL time. Almost everything I write is done when the kids are in bed and I’m watching TV. I have often had to take my own vacation time to teach CE classes or attend some meetings. Believe it or not I still find time to have a normal life with my family for vacations, kids activities, movies, and life.
If you doubt what regular ol’ working librarians can do please do a little looking into Ohio Public Libraries, 2009, budget cuts, and Governor Strickland. In 2009, out of the blue the Ohio governor proposed a 50% cut funding to public libraries. This type of cut would close many public libraries and leave many irreparably devastated. Within 1 hour of the announcement the story hit Twitter and the hashtag #saveohiolibraries was created to categorize the Twitter messages. A Facebook site was created and had over 50,000 followers in less than 3 weeks. Another librarian created a website, www.saveohiolibraries.com. Not only did they get national attention but the Ohio legislature received between 37,000-45,000 emails in one week regarding the budget cuts.
(I live in Ohio so I remember much of this but I was able to find the specifics in the Introduction of Laura Solomon’s book the Librarian’s Nitty Gritty Guide to Social Media)
The thing to note was that ALA didn’t get involved within an an hour of the announcement. Much of the ground work was done by regular librarians like you and me who saw the immediate need to advocate for their jobs. Given the differences between the funding of medical libraries and public libraries, I think we medical librarians can’t afford to wait for the budget cut announcement. We need to advocate for ourselves now! MLA is helpful and they will do what they humanly can to support us. But we need to stop looking to them to make everything all better, we need to get the message out in whatever way possible.
I understand, we all are worried about the future of medical and hospital libraries. Just because I have a full time job and and I’m active in the organization doesn’t mean I am not worried. In fact it makes me more worried because I have seen how easily it can turn. But I refuse to sit back and subscribe to what some of the “realist” librarians have said, “It doesn’t matter how proactive we are; it doesn’t matter who gets involved; it doesn’t matter how many people come to our defense; it doesn’t matter how much evidence we have to justify our positions; it doesn’t matter how much time we save for others; it doesn’t matter that after we are gone there will be problems for people who need our services. All of that weighed against the decision of the ‘powers that be’ that they can cut the librarian will not help. They will not change their minds.” To those realists I say, “There’s no fate but what we make for ourselves.” I see you what you have made for your fate. Your fate is not mine.
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Yesterday I read an interesting piece by Oliver Obst, “Trust no guideline that you did not fake yourself.” (Journal of EAHIL. 2013. v9 (4) p25) Obst references the German newspaper Frankfurter Allgemeine Zeitung, which reported several cases of fake practice guidelines. I don’t read German and it appears you must pay to access FAZ’s article archive, but if you read German and have access to the archive, the link to the article is here. According Obst’s summation of the article and Google Translate’s translated version of the abstract, the newspaper attributes thousands of deaths in Europe due to guidelines from the European Society of Cardiology and scientific misconduct.
Unfortunately this is not a single incident, Obst reports “many more examples can be found in a disturbing report by Jeanne Lenzer in the British Medical Journal, ‘Why we cannot trust clinical guidelines.” Lenzer’s article reports that doctors with ties to pharma companies are writing the guidelines. Since most guidelines are written by a large group of doctors you would think it would be difficult to have financial bias make any sort of impact on the guidelines. However, Lenzer discovered a survey showing that it is entirely possible.
“A recent survey found that 71% of chairs of clinical policy committees and 90.5% of co-chairs had financial conflicts.12 Such conflicts can have a strong impact: FDA advisers reviewing the safety record of the progestogen drospirenone voted that the drug’s benefits outweighed any risks. However, a substantial number of the advisers had ties to the manufacturer and if their votes had been excluded the decision would have been reversed.13“
The Cochrane Collection is not immune either according to Lenza.
Early 1990′s-Reinforced by a Cochrane review, high dose steroids became the standard of care for acute spinal cord injury. The Cochrane Collaboration, permitted Michael Bracken, “who declared he was an occasional consultant to steroid manufacturers Pharmacia and Upjohn, to serve as the sole reviewer.”
The standard was just reversed in March 2013 with the Congress of Neurological Surgeons new guidelines. They found, “There is no Class I or Class II medicine evidence supporting the benefit of [steroids] in the treatment of acute [spinal cord injury]. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects including death.”11
Lenza believes another example of biased guidelines is beginning to emerge regarding stroke and the use of alteplase.
“American College of Emergency Physicians with the American Academy of Neurology (jointly)18 and the American Heart Association,19 separately, issued grade A level of evidence guidelines for alteplase in acute stroke. The simultaneous recommendation by three respected professional societies would seem to indicate overwhelming support for the treatment and consistent evidence. However, an online poll of 548 emergency physicians showed that only 16% support the new guidelines.20“
Lenza points out that “claims of benefit rest on science that is contested. Sceptics say that baseline imbalances, the use of subset analyses, and chance alone could account for the claimed benefit.24 26 31 32 33 They also note that only two of 12 randomised controlled trials of thrombolytics have shown benefit and five had to be terminated early because of lack of benefit, higher mortality, and significant increases in brain haemorrhage.”33 Lenza also notes that “13 of the 15 authors had ties to the manufacturers of products to diagnose and treat acute stroke; 11 had ties to companies that market alteplase.”19
So what does this mean for librarians as we try and find the best research out there for our doctors, nurses and patients? This is a problem. Even if you take out the pharma bias, bio-medical scientific literature rarely publishes work on failures. Add the pressure from pharma wanting and promoting positive outcome research to published, we have even fewer examples of “what didn’t work” research articles and quite possibly what we thought was good evidence isn’t as good as we thought.
As Obst notes, librarians must be aware of this issue and to keep our patrons informed. Unfortunately this may be the only thing we can do and even then it might not be enough. Lenza ends her article by saying;
“Yet these and other guidelines continue to be followed despite concerns about bias, because as one lecturer told a meeting on geriatric care in the Virgin Islands earlier this year, ‘We like to stick within the standard of care, because when the shit hits the fan we all want to be able to say we were just doing what everyone else is doing—even if what everyone else is doing isn’t very good.”Share on Facebook
Don’t think of it as a New Year’s resolution, think of it as just taking inventory of your career path. Whether you are looking to find a new job in a new organization or just trying to add a new direction to your current job, it is a good idea to think about, evaluate, and discuss (pick people’s brains) your ideas and options.
So tune in to #medlibs on Twitter tonight at 9pm Eastern.
See you there.
Reposted form (Medlibschapt.blogspot.com)
Join Heather Holmes (@LaMedBoheme73) and Michelle Kraft (@Krafty) for this week’s #medlibs talk as we discuss all good things related to jobs, such as: looking for a new job, preparations to move (yourself, your family, etc), learning or brushing up on skills, transitioning to a new position in the same institution, or transitioning to a related but totally different position. What are some of the positive reasons you are looking for or have accepted a new position or are seeking new skills and abilities? This won’t be a rant session, we want it to be a positive and constructive discussion so please join us and spread the word – we’d love to welcome library students and others interested in learning more about the field!
Some resources to consider:
I stumbled across this blog post a week ago and thought it was a wonderful example of the way social media can be used to better biomedical science.
The New England Journal of Medicine published an article in June on the prevention of MRSA in the ICU. The study was very large, 74,256 patients, and the results looked impressive, BUT nobody could get the stats didn’t add up. The numbers given in the published paper didn’t correlate with the Number-Needed to Treat (NNT)
A blog post on Intensive Care Network posted the following about the stats in the NEJM article:ARE THE STATS CORRECT?
We were hashing this out in our journal club, but could not get the stats to add up.
If you can PLEASE COMMENT HERE!
The NNT’s of 54 and 181 seem impossibly small, with huge clinical implications.
Please try it yourself; look at Table 3. Frequency and Rates of Outcomes during the Baseline and Intervention Periods, According to Study Group
With bloodstream infection from any pathogen, the Group 1 (standard care) number of events per 1000 patient days is 4.1. With Group 3, the number of events is 3.6 per 1000 patients days. Even taking change from baseline into account and assuming these NNTs have been calcuated AFTER randomization, between Group 1 and Group 3, we get nowhere close to their NNT’s.
PLEASE have a go and see if you can match their NNT’s.
IF you can’t there is a serious problem, with practice changing implications.
It’s too late to write letters to the NEJM, so a robust discussion in a peer reviewed forum seems a good way to go.
The authors of blog post intention was to discuss the problem in “a peer reviewed forum” and according to them “there was lots of insightful commentary from around the globe.”
The fact that they were able to discuss problem with others around world is big but not unheard of, more and more scientists are discussing issues online. To me the biggest thing is that the paper’s lead author, Susan Huang engaged in a discussion with the social media reviewers with a “prompt and gracious reply” agreed the published calculation was an error and showed “true scientific and academic integrity by contacting the NEJM as soon as there was a suggestion that the stats were incorrect.” NEJM responded by publishing an correction to the paper.
It is very cool how scientists discussed online a paper’s validity and work together to essentially provide world wide peer review. However, what I find even cooler is that the author was engaged with the social media process AND a respected journal addressed and responded to the findings. This is an example of everything that is right with social media and professional communication. It will be interesting to see if we will see more of this type of world peer review in the future especially now that PubMed Commons can also foster this kind of scientific inquiry and discussion.
NEJM is a big journal with lots of very smart authors contributing papers that are subjected to very peer reviewers, but still there can be mistakes. World peer review via social media could help improve the process. One question I keep wondering is, if we have this type of world peer review, could this cut down on the academic fraud that sometimes eludes the careful eyes of publishers’ peer reviewers? What would have happened had Wakefield’s fraudulent study linking vaccines and autism (published in 1998) been published today? Would that paper have had a chance to make it the general public’s consciousness and be as unfortunately influential as it still is today?
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The Medicine 2.0 movement is largely led by Dr. Gunther Eysenbach at the University of Toronto. His landmark article in the Journal of Medical Internet Research, which he edits, was published in 2008 and is entitled “Eysenbach G. Medicine 2.0: social networking, collaboration, participation, apomediation, and openness” (as well as its companion piece Health 2.0 and medicine 2.0: tensions and controversies in the field). These papers are central documents in understanding the complementary web 2.0 trends e.g., Health 2.0 & Medicine 2.0 …they are definitely worth a close reading.
Now, five years later, the Medicine 2.0 movement in 2013 is hosting in London its sixth international congress on social media (and mobile apps and ‘web 2.0′). I really wish I could attend….However, in looking at the online abstracts, I can see that there is a good Canadian presence at the conference, and a considerable amount of content for medical and health librarians interested in medicine 2.0 topics. (Download the conference document and search for Canad* and librar* to see what I mean).
Note the oral presentation by CHLA/ABSC members on pg. 331
Helen Lee Robertson, Jill Boruff, Dagmara Chojecki, Dale Storie, Lee-Ann Ufholz. “What are they really doing on that smartphone? How medical students, residents and faculty use their mobile devices”