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Research Studies is a monthly compilation of research articles funded by AHRQ or authored by AHRQ researchers and recently published in journals or newsletters.
Results1 to 25 of 28 Research Studies Displayed
Werner RM, Konetzka RT, Qi M
The impact of Medicare copayments for skilled nursing facilities on length of stay, outcomes, and costs.
The objective of this study was to investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs. The investigators concluded that Medicare's SNF copayment policy was associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy had unintended and negative effects on patient outcomes.
Citation: Werner RM, Konetzka RT, Qi M . The impact of Medicare copayments for skilled nursing facilities on length of stay, outcomes, and costs. Health Serv Res 2019 Dec;54(6):1184-92. doi: 10.1111/1475-6773.13227..
Keywords: Medicare, Nursing Homes, Payment, Long-Term Care, Healthcare Costs, Elderly, Hospitalization, Hospital Discharge
McCreedy E, Ogarek JA, Thomas KS
The minimum data set agitated and reactive behavior scale: measuring behaviors in nursing home residents with dementia.
Researchers in this study test the internal consistency and construct validity of the Agitated and Reactive Behavior Scale (ARBS), a measure created to measure agitated and aggressive behaviors in dementia residents at nursing homes (NHs). This cross-sectional study used data from the 2016 national sample of 15,326 Centers for Medicare and Medicaid Services-certified NHs. The sample included 489,854 new admissions and 765,367 long-stay residents (defined as 90 days or more) all diagnosed with dementia. The ARBS is a composite measure of physical and verbal agitation or aggressiveness towards other people; other behavioral symptoms not directed at other people; and rejection of care. The study found that 1) the ARBS score has borderline-adequate internal consistency in the national population of NH residents with dementia; 2) only 18% of new admissions, and 21% of long-stay residents with dementia displayed any aggressive or agitated behaviors in the previous week; and 3) the ARBS demonstrated good construct validity. Conclusions were that nationally available MDS data may significantly underestimate the prevalence of agitated and aggressive behaviors among NH dementia patients.
Citation: McCreedy E, Ogarek JA, Thomas KS . The minimum data set agitated and reactive behavior scale: measuring behaviors in nursing home residents with dementia. J Am Med Dir Assoc 2019 Dec;20(12):1548-52. doi: 10.1016/j.jamda.2019.08.030..
Keywords: Elderly, Dementia, Neurological Disorders, Nursing Homes, Long-Term Care, Behavioral Health
Palmer JA, Parker VA, Barre LR
Understanding implementation fidelity in a pragmatic randomized clinical trial in the nursing home setting:a mixed-methods examination.
This randomized clinical trial called Pragmatic Trial of Video Education in Nursing Homes (PROVEN) was one of the largest trials to be conducted in nursing homes on education of residents in Advanced Care Planning (ACP). The trial used videos with champions promoting ACP education across two large health-care systems. The trial length was 18 months, with champions offering video education to the residents every six months. At the end of the study 28 interviews involving 33 champions were analyzed. The researchers found different patterns between high- and low-adherence nursing homes. High-adherence nursing homes had more family and patient willingness to engage in the program and champions were better at recruitment. Champions also supplemented the video with ACP conversations.
Citation: Palmer JA, Parker VA, Barre LR . Understanding implementation fidelity in a pragmatic randomized clinical trial in the nursing home setting:a mixed-methods examination. Trials 2019 Nov 28;20(1):656. doi: 10.1186/s13063-019-3725-5..
Keywords: Nursing Homes, Long-Term Care, Education: Patient and Caregiver, Health Literacy, Patient and Family Engagement, Elderly
Kapoor A, Field T, Handler S
Characteristics of long-term care residents that predict adverse events after hospitalization.
This study examined the characteristics of long-term care (LTC) residents that predict adverse events (AEs) after discharge from recent hospitalization. This cohort study looked at AEs that occurred at 32 nursing homes from six New England states. AE incidents involving a total of 555 LTC residents with 762 transitions from the hospital back to LTC were reviewed. The association between all AEs and preventable AEs developing in the 45 days following discharge back to LTC was measured. There were 283 discharges with one or more AEs and 212 with preventable AEs. Characteristics independently associated with higher risk of AEs included hospital length of stay (LOS) 9 or more days, 18 or more regularly scheduled medications, and 19 and above on the dependency in activities of daily living (ADL) scale.
Citation: Kapoor A, Field T, Handler S . Characteristics of long-term care residents that predict adverse events after hospitalization. J Am Geriatr Soc 2020 Nov;68(11):2551-57. doi: 10.1111/jgs.16770..
Keywords: Elderly, Long-Term Care, Nursing Homes, Hospitalization, Adverse Events, Transitions of Care, Hospital Discharge, Risk
Hua CL, Thomas KS
Coronavirus Disease 19 (COVID-19) restrictions and loneliness among residents in long-term care communities: data from the National Health and Aging Trends Study.
Loneliness has been associated with increased morbidity and mortality among older adults, especially among residents of long-term care (LTC) facilities. COVID-19 disproportionately contributed to deaths in LTC communities during pandemic, especially before the introduction of vaccines. Restrictive measures were instituted in many LTC facilities to try to slow the spread of COVID-19. This report examines whether these restrictive measures were associated with increased loneliness among older adults in LTC communities during the pandemic. Data from the 2020 National Health and Aging Trends Study (NHATS) COVID-19 supplement, a representative sample of Medicare beneficiaries (age 65 and older) was used, with 234 residents participating. Surveys completed by proxies were excluded because loneliness measures were not available. Approximately 28.7% of residents in LTC communities were lonelier during the pandemic than pre-pandemic. Residents who could not leave their rooms appeared to show increased loneliness.
Citation: Hua CL, Thomas KS . Coronavirus Disease 19 (COVID-19) restrictions and loneliness among residents in long-term care communities: data from the National Health and Aging Trends Study. J Am Med Dir Assoc 2021 Sep;22(9):1860-61. doi: 10.1016/j.jamda.2021.06.029..
Keywords: COVID-19, Elderly, Long-Term Care, Nursing Homes
Olivieri-Mui BL, Koethe B, Briesacher B
Economic barriers to antiretroviral therapy in nursing homes.
In this study, the investigators’ aim was to clarify if persons living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) have adequate economic access to antiretroviral therapy (ART) when admitted to nursing homes (NHs). They concluded that people living with HIV in NHs do not always receive lifesaving ART, but the reasons are unclear and appear unrelated to economic barriers.
Citation: Olivieri-Mui BL, Koethe B, Briesacher B . Economic barriers to antiretroviral therapy in nursing homes. J Am Geriatr Soc 2020 Apr;68(4):777-82. doi: 10.1111/jgs.16288..
Keywords: Human Immunodeficiency Virus (HIV), Nursing Homes, Long-Term Care, Medication, Access to Care
Sharma H, Konetzka RT, Smieliauskas F
The relationship between reported staffing and expenditures in nursing homes.
Citation: Sharma H, Konetzka RT, Smieliauskas F . The relationship between reported staffing and expenditures in nursing homes. Med Care Res Rev 2019 Dec 1;76(6):758-83. doi: 10.1177/1077558717739214..
Keywords: Nursing Homes, Long-Term Care, Quality Improvement, Quality of Care, Provider Performance, Medicare
McKinnell JA, Singh RD, Miller LG
The SHIELD Orange County project: multidrug-resistant organism prevalence in 21 nursing homes and long-term acute care facilities in Southern California.
The authors reported baseline multidrug-resistant organism (MDRO) prevalence in 21 nursing homes (NHs) and long-term acute care facilities (LTACs). They found that prevalence of MDROs was 65% in NHs and 80% in LTACs. They concluded that the majority of NH residents and LTAC patients harbor MDROs, and that MDRO status is frequently unknown to the facility. The high MDRO prevalence highlights the need for prevention efforts in NHs/LTACs as part of regional efforts to control MDRO spread.
Citation: McKinnell JA, Singh RD, Miller LG . The SHIELD Orange County project: multidrug-resistant organism prevalence in 21 nursing homes and long-term acute care facilities in Southern California. Clin Infect Dis 2019 Oct 15;69(9):1566-73. doi: 10.1093/cid/ciz119.
Keywords: Nursing Homes, Long-Term Care, Methicillin-Resistant Staphylococcus aureus (MRSA), Healthcare-Associated Infections (HAIs), Patient Safety
Berry SD, Zullo AR, Zhang T
Validation of the FRAiL model to predict non-vertebral and hip fractures in nursing home residents.
This study created a tool to assess non-vertebral and hip fracture risk in long-term nursing home (NH) residents called FRAiL (Fracture Risk Assessment in Long term care). The objective of this retrospective cohort study was to assess the performance of the model to predict 2-year risk of fractures in a separate large cohort of NH residents. The study included most long-stay NH residents in the United States (n = 896,840). Fractures were identified using Medicare claims. The mean age of NH residents was 83.8 years and 70.7% were women. Over the 2-year follow-up period 4.6% were hospitalized with non-vertebral fractures, the majority being hip fractures. In the fully adjusted model, 14 out of 15 model characteristics remained significant predictors of non-vertebral fractures. Female sex, wandering, and falls were strongly associated with non-vertebral fractures.
Citation: Berry SD, Zullo AR, Zhang T . Validation of the FRAiL model to predict non-vertebral and hip fractures in nursing home residents. Bone 2019 Nov;128:115050. doi: 10.1016/j.bone.2019.115050..
Keywords: Elderly, Nursing Homes, Long-Term Care, Injuries and Wounds
White EM, Aiken LH, McHugh MD
Registered nurse burnout, job dissatisfaction, and missed care in nursing homes.
The purpose of this article was to examine the relationship between registered nurse (RN) burnout, job dissatisfaction, and missed care in nursing homes. The investigators concluded that missed nursing care due to inadequate time or resources is common in nursing homes and is associated with RN burnout and job dissatisfaction; they indicated that improved work environments with sufficient staff hold promise for improving care and nurse retention.
Citation: White EM, Aiken LH, McHugh MD . Registered nurse burnout, job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc 2019 Oct;67(10):2065-71. doi: 10.1111/jgs.16051..
Keywords: Provider: Nurse, Provider, Burnout, Nursing Homes, Long-Term Care, Workforce
Popescu I, Sood N, Joshi S
Trends in the use of skilled nursing facility and home health care under the Hospital Readmissions Reduction Program: an interrupted time-series analysis.
Medicare's Hospital Readmission Reduction Program penalizes hospitals with elevated 30-day readmission rates for acute myocardial infarction, heart failure, or pneumonia. The authors investigated if, in order to reduce readmissions, hospitals may have increased referrals to skilled nursing facilities and home health care. They found that hospitals might be shifting to more intensive postacute care to avoid readmissions among seniors with pneumonia. At the same time, penalized hospitals' efforts to prevent readmissions may be keeping higher proportions of their patients in the community.
AHRQ-funded; HS024284; HS025394.
Citation: Popescu I, Sood N, Joshi S . Trends in the use of skilled nursing facility and home health care under the Hospital Readmissions Reduction Program: an interrupted time-series analysis. Med Care 2019 Oct;57(10):757-65. doi: 10.1097/mlr.0000000000001184..
Keywords: Home Healthcare, Nursing Homes, Chronic Conditions, Hospital Readmissions, Long-Term Care, Hospitals, Heart Disease and Health, Pneumonia, Cardiovascular Conditions
Kapoor A, Field T, Handler S
Adverse events in long-term care residents transitioning from hospital back to nursing home.
This study looked at adverse event rates of long-term care residents transitioning back to their nursing home after hospitalization. A prospective cohort study of LTC residents discharged from hospital back to LTC from March 1, 2016, to December 31, 2017 was conducted, and residents were followed up for 45 days. A random sample of 32 nursing homes located in 6 New England states was used, and 555 LTC residents were selected, contributing 762 transitions from hospital back to the same LTC facility. Most of the cohort were female (65.5%) and non-Hispanic white (93.7%). The study used trained nurse abstractors to review nursing home records to determine if an adverse event occurred. Out of 762 discharges there were 379 adverse events. The most common adverse events were pressure ulcers, skin tears, and falls followed by health care-acquired infections. 145 adverse events were considered less serious, with 28 life-threatening, and 8 were fatal. Most of the adverse events were considered preventable or ameliorable.
Citation: Kapoor A, Field T, Handler S . Adverse events in long-term care residents transitioning from hospital back to nursing home. JAMA Intern Med 2019 Sep;179(9):1254-61. doi: 10.1001/jamainternmed.2019.2005..
Keywords: Adverse Events, Long-Term Care, Nursing Homes, Transitions of Care, Elderly, Patient Safety, Hospital Discharge, Hospitalization
Zhang T, Lary CW, Zullo AR
Post-hip fracture mortality in nursing home residents by obesity status.
This research letter discusses a study that examined whether obesity status affected mortality in post-hip fracture patients who were nursing home residents. A national cohort of nursing home (NH) residents was examined from national Medicare fee-for-service claims linked to the Minimum Data Set (MDS) from January 2008 through the end of 2009. A total of 33, 622 long-stay residents were identified who had been hospitalized for a hip fracture. They excluded 6918 patients due to a number of factors. They classified residents based on their BMI: normal BMI, overweight, mild obesity, or moderate/severe obesity. They found that being moderate/severely obese did not increase mortality.
Citation: Zhang T, Lary CW, Zullo AR . Post-hip fracture mortality in nursing home residents by obesity status. J Am Geriatr Soc 2019 Sep;67(9):1983-85. doi: 10.1111/jgs.16028..
Keywords: Injuries and Wounds, Surgery, Nursing Homes, Obesity, Mortality, Elderly, Long-Term Care, Patient-Centered Outcomes Research
Libertucci J, Bassis CM, Cassone M
Bacteria detected in both urine and open wounds in nursing home residents: a pilot study.
Researchers sought to determine if bacterial species colonizing open wounds are also found in the urine. Their pilot study of nursing home residents provided evidence that bacterial species identified within the urine can also be identified in open wounds in the same patient at one point in time. They recommended further studies to investigate if these species are of the same lineage and if the urinary microbiota are able to seed colonization of open wounds below the umbilicus.
Citation: Libertucci J, Bassis CM, Cassone M . Bacteria detected in both urine and open wounds in nursing home residents: a pilot study. mSphere 2019 Aug 28;4(4). doi: 10.1128/mSphere.00463-19..
Keywords: Elderly, Nursing Homes, Long-Term Care, Healthcare-Associated Infections (HAIs), Injuries and Wounds, Patient Safety
Orth J, Li Y, Simning A
Providing behavioral health services in nursing homes is difficult: findings from a national survey.
This study evaluated access to behavioral health services in nursing homes (NHs). A random sample of 2996 NHs in the United States was identified. Two structured surveys were developed with questions on service availability, quality, satisfaction, staffing, staff education, turnover and service barriers. The surveys were mailed to administrators and directors of nursing in NHs between July and December 2017. The results showed that over 30% reported having inadequate coordination of care between NHs and community providers, and 26.2% had inadequate infrastructure for resident referrals or transport. Staff education was the most important factor associated with subpar provision of behavioral health services in nursing homes.
Citation: Orth J, Li Y, Simning A . Providing behavioral health services in nursing homes is difficult: findings from a national survey. J Am Geriatr Soc 2019 Aug;67(8):1713-17. doi: 10.1111/jgs.16017..
Keywords: Elderly, Nursing Homes, Behavioral Health, Access to Care, Long-Term Care, Healthcare Delivery
Perraillon MC, Brauner DJ, Konetzka RT
Nursing home response to Nursing Home Compare: the provider perspective.
This paper examined the validity of quality ratings of nursing homes with Nursing Home Compare (NHC) and assessed the views of nursing home administrators and staff. There was a conflict found between improving ratings and competing goals of maximizing profits and avoidance of litigation. Since the NHC is self-reported there is controversy on its validity due to self-reporting bias.
Citation: Perraillon MC, Brauner DJ, Konetzka RT . Nursing home response to Nursing Home Compare: the provider perspective. Med Care Res Rev 2019 Aug;76(4):425-43. doi: 10.1177/1077558717725165..
Keywords: Long-Term Care, Nursing Homes, Provider Performance, Quality of Care, Quality Improvement, Value
Gorges RJ, Sanghavi P, Konetzka RT
A national examination of long-term care setting, outcomes, and disparities among elderly dual eligibles.
The authors investigated the outcomes of expanding Medicaid funding for long-term care home and community-based services (HCBS). Using national Medicaid claims data on older adults enrolled in both Medicare and Medicaid, they found that overall hospitalization rates were similar for HCBS and nursing facility users. They concluded that home and community-based services need to be carefully targeted to avoid adverse outcomes and that the racial/ethnic disparities in access to high-quality institutional long-term care are also present in HCBS.
Citation: Gorges RJ, Sanghavi P, Konetzka RT . A national examination of long-term care setting, outcomes, and disparities among elderly dual eligibles. Health Aff 2019 Jul;38(7):1110-18. doi: 10.1377/hlthaff.2018.05409..
Keywords: Elderly, Medicaid, Medicare, Long-Term Care, Home Healthcare, Disparities, Racial / Ethnic Minorities
Tandan M, Sloane PD, Ward K
Antimicrobial resistance patterns of urine culture specimens from 27 nursing homes: impact of a two-year antimicrobial stewardship intervention.
This study evaluated the impact of a two-year antimicrobial stewardship intervention program at 27 nursing homes. The objective was to identify changes in the prevalence and antimicrobial resistance patterns of potentially pathogenic bacteria in urine cultures. All urine cultures were audited during the time period, and out of 6,718 total urine cultures collected, 68% were positive for potentially antimicrobial resistant bacteria. Most of the bacteria identified were E. coli, Proteus spp, and Klebsiella pneumonia. During the 2-year program there was a significant decrease in nitrofurantoin resistance among E. coli and ciprofloxacin resistant among Proteus spp, but carbanepem resistance increased for Proteus spp. Overall, while there was some reduction in antibiotic resistance, the reductions were too small and scattered to conclude the intervention made a big impact.
Citation: Tandan M, Sloane PD, Ward K . Antimicrobial resistance patterns of urine culture specimens from 27 nursing homes: impact of a two-year antimicrobial stewardship intervention. Infect Control Hosp Epidemiol 2019 Jul;40(7):780-86. doi: 10.1017/ice.2019.108..
Keywords: Antibiotics, Antimicrobial Stewardship, Elderly, Long-Term Care, Medication, Nursing Homes
Coe NB, Guo J, Konetzka RT
AHRQ Author: Guo J
What is the marginal benefit of payment-induced family care? Impact on Medicaid spending and health of care recipients.
Research on home-based long-term care has centered almost solely on the costs; there has been very little, if any, attention paid to the relative benefits. This study exploited the randomization built into the Cash and Counseling Demonstration and Evaluation program that directly impacted the likelihood of having family involved in home care delivery. The investigators found that some family involvement in home-based care significantly decreased health-care utilization: lower likelihood of emergency room use, Medicaid-financed inpatient days, any Medicaid hospital expenditures, and fewer months with Medicaid-paid inpatient use.
Citation: Coe NB, Guo J, Konetzka RT . What is the marginal benefit of payment-induced family care? Impact on Medicaid spending and health of care recipients. Health Econ 2019 May;28(5):678-92. doi: 10.1002/hec.3873..
Keywords: Home Healthcare, Long-Term Care, Medicaid
Hass Z, Woodhouse M, Grabowski DC
Assessing the impact of Minnesota's return to community initiative for newly admitted nursing home residents.
This study evaluated the Minnesota Return to Community Initiative (RTCI) program which facilitates community discharge of non-Medicaid nursing home residents. It was implemented statewide without a control group. The program assists with discharge planning, transitioning to the community, and postdischarge follow-up. Results showed the program increased discharge rates by an estimated 11 percent. Success increased with time as nursing home facilities increased their participation.
Citation: Hass Z, Woodhouse M, Grabowski DC . Assessing the impact of Minnesota's return to community initiative for newly admitted nursing home residents. Health Serv Res 2019 Jun;54(3):555-63. doi: 10.1111/1475-6773.13118..
Keywords: Care Coordination, Long-Term Care, Nursing Homes, Transitions of Care
Alexander GL, Powell K, Deroche CB
Building consensus toward a national nursing home information technology maturity model.
This study describes the development of a nursing home information technology (IT) maturity model in 2 phases. The first phase was to develop a preliminary maturity model. Phase II involved 3 rounds of questionnaires using a Delphi panel of expert nursing home administrators. Three Delphi rounds were done, and this evolved the model from 5-stages (stages 1-5) to a 7-stage model (stages 0-6).
Citation: Alexander GL, Powell K, Deroche CB . Building consensus toward a national nursing home information technology maturity model. J Am Med Inform Assoc 2019 Jun;26(6):495-505. doi: 10.1093/jamia/ocz006..
Keywords: Health Information Technology (HIT), Long-Term Care, Nursing Homes
Fabius CD, Thomas KS
Examining black-white disparities among Medicare beneficiaries in assisted living settings in 2014.
The purpose of this study examined racial differences among a national cohort of assisted living (AL) residents and how the racial variation among AL Medicare Fee-For-Service (FFS) beneficiaries compared to differences among community-dwelling and nursing home cohorts. Using the Medicare Master Summary Beneficiary File, researchers found that black patients were disproportionately represented in AL, younger, more likely to be Medicaid eligible, had higher levels of acuity, and more often lived in ALs with fewer whites and more patients with dual eligibility. Further, new black residents entered AL with higher rates of acute care hospitalizations and skilled nursing facility utilization. Further research is recommended.
Citation: Fabius CD, Thomas KS . Examining black-white disparities among Medicare beneficiaries in assisted living settings in 2014. J Am Med Dir Assoc 2019 Jun;20(6):703-09. doi: 10.1016/j.jamda.2018.09.032..
Keywords: Disparities, Elderly, Long-Term Care, Medicare, Racial / Ethnic Minorities
Perraillon MC, Konetzka RT, He D
Consumer response to composite ratings of nursing home quality.
Health care report cards are intended to address information asymmetries and enable consumers to choose providers of better quality. This study examined whether the form of the information mattered to consumers. The investigators concluded that the form of quality reporting mattered to consumers, and that the increased use of composite ratings was likely to increase consumer response.
AHRQ-funded; HS021877; HS021861; HS000084.
Citation: Perraillon MC, Konetzka RT, He D . Consumer response to composite ratings of nursing home quality. Am J Health Econ 2019 Spring;5(2):165-90. doi: 10.1162/ajhe_a_00115..
Keywords: Nursing Homes, Long-Term Care, Quality of Care, Provider Performance, Quality Measures
Hanlon JT, Perera S, Drinka PJ
The IOU consensus recommendations for empirical therapy of cystitis in nursing home residents.
A 19-member panel of clinical pharmacists was convened for the Improving Outcomes of UTI Management in Long-Term Care Project (IOU) funded by the Agency for Healthcare Research and Quality. The objective is to reach consensus on a set of recommendations for the empirical treatment of cystitis in older nursing home residents with oral anti-infective medications. A comprehensive literature search was conducted and out of that 31 recommendations were created. There were two Delphi Survey rounds conducted and those recommendations were rated on a 5-point Likert scale. In the first round three recommendations reached consensus and in the second round an additional eight recommendations were agreed on.
Citation: Hanlon JT, Perera S, Drinka PJ . The IOU consensus recommendations for empirical therapy of cystitis in nursing home residents. J Am Geriatr Soc 2019 Mar;67(3):539-45. doi: 10.1111/jgs.15726..
Keywords: Elderly, Nursing Homes, Long-Term Care, Medication, Quality Improvement, Quality of Care, Evidence-Based Practice
Carnahan RM, Daly JM, Minion S
A needs assessment of family physicians to inform development of educational resources on antipsychotic use in dementia.
The authors assessed the needs and preferred resources of Iowa physicians to inform the development of educational resources for best practice dementia care and compared the responses of nursing home medical directors with nonmedical directors. They found that medical directors and nonmedical directors had similar preferences for resources used and information needs, with preference for online resources, pocket guides, a handbook, consulting pharmacists, and facility in-services being the most commonly preferred sources of new information. Medical directors were significantly more aware of the FDA warning on antipsychotic use in dementia and treated more nursing home patients. No differences were observed between groups related to confidence in and use of nondrug strategies instead of antipsychotics to manage behavioral symptoms of dementia.
Citation: Carnahan RM, Daly JM, Minion S . A needs assessment of family physicians to inform development of educational resources on antipsychotic use in dementia. J Prim Care Community Health 2019 Jan-Dec;10:2150132719840113. doi: 10.1177/2150132719840113..
Keywords: Education: Continuing Medical Education, Medication, Dementia, Neurological Disorders, Elderly, Evidence-Based Practice, Guidelines, Long-Term Care