Durham VA Health Care System

Hospital mobility programs align with age-friendly care principles by promoting functional recovery for older adults; however, optimal strategies for implementing such programs remain unclear. To compare two approaches for implementing the STRIDE hospital mobility program across Veterans Affairs (VA) hospitals. Parallel cluster randomized controlled trial in 35 VA hospitals, with hospitals assigned to foundational (n = 19) or enhanced (n = 16) support arms. General medicine hospitalizations among patients aged 60years and older. Foundational support included access to standardized program materials, online resources, data dashboards, and peer mentoring. Enhanced support included tailored 1:1 facilitation sessions for hospitals failing to meet initial program activity benchmarks. Primary outcomes were penetration (hospitalizations with ≥ 1 STRIDE walk), fidelity (hospital days meeting walking activity benchmarks), and program adoption. During the 10-month observation period, median number of hospitalizations with a STRIDE walk was 70 in the foundational arm (IQR 3-131; range 0-374) and 34 in the enhanced arm (IQR 15-72; range 0-370). At 10-months, in adjusted models, there were no differences between arms in estimated percentage of hospitalizations with at least one STRIDE walk (1.9% in enhanced support and 4.0% in foundational support with estimated mean difference of -2.1% [95% CI -5.0%, 0.8%; p = 0.15]), or STRIDE hospital days meeting fidelity metrics (37.7% in enhanced support and 32.3% in foundational support with estimated mean difference of 5.3% [95% CI -6.0%, 16.6%; p = 0.34]). Overall rates of STRIDE initiation were 81% (n = 13) in the enhanced arm and 74% (n = 14) in the foundational arm. Barriers and facilitators to implementation were similar across arms. This study found no significant advantage of enhanced over foundational support for implementing the STRIDE hospital mobility program. Development of targeted implementation strategies to improve reach is needed to enhance overall impact of hospital mobility programs and age-friendly care initiatives. ClinicalTrials.gov (identifier NCT04868656).

This article presents a caregiver-centered framework that categorizes the experiences of caregivers to align unmet caregiver needs with relevant supports. The study applied a partner-engaged, qualitative, mixed-methods approach. Using findings from a qualitative evidence synthesis, facilitated data sorting, and caregiver focus groups, the team developed and refined a conceptual model comprised of four key components: phases, goals, stressors, and multilevel contextual factors. This model was simplified into a framework of ten categories of caregiving experiences that are widely applicable to the US caregiving context. This framework is a tool for healthcare and social service professionals to target caregiver supports.

ABSTRACTObjectivesPain is common among patients presenting to the emergency department (ED) but is frequently underdetected and undertreated in older people living with dementia (PLWD). This systematic review examined whether dementia‐specific pain assessment tools improve pain management compared with usual care in the ED.MethodsWe conducted a systematic review and have reported the methods and results following PRISMA (PROSPERO: CRD420251044828). Eligible studies included randomized, quasi‐experimental, and observational designs enrolling ED patients aged ≥ 65 years with dementia or cognitive impairment. Interventions were pain assessment tools developed for PLWD, and comparisons were with standard pain scales. Primary outcomes were patient‐reported outcome measures and analgesia administration; secondary outcomes included repeated pain scores, ED revisits, functional decline, mortality, and adverse events. Five databases (Ovid MEDLINE, Embase, Cochrane Library, CINAHL, PsycInfo) and two clinical trial registries were searched without language or date restrictions on April 22, 2025, and December 16, 2025, respectively. Two reviewers independently screened, extracted data, and assessed risk of bias using Cochrane RoB‐2.ResultsOf 987 records identified, 18 underwent full‐text review, and one study met eligibility criteria. Fry et al. (2017) conducted a multicenter, cluster‐randomized controlled trial of 602 older adults with suspected long bone fractures, comparing the Pain Assessment in Advanced Dementia (PAINAD) tool with standard pain scales. No significant differences were observed in median time to first analgesia (83 vs. 82 min, p = 0.42) or proportion receiving analgesia within 60 min (28% vs. 32%, p = 0.19). Evidence certainty was rated very low.ConclusionsEvidence on dementia‐specific pain assessment tools in the ED is extremely limited. Available data suggest PAINAD does not improve timeliness of analgesia, underscoring the urgent need for rigorous studies to guide pain management for PLWD in the ED.

BackgroundIn intensive care units (ICUs), shared decision making (SDM) between clinicians and families is critical for evaluating complex tradeoffs of life-sustaining treatments and making patient-centered decisions, yet clinicians are less likely to engage in SDM with Black compared to White families.ObjectiveTo describe how Black compared to White family members experienced medical decision making about life-sustaining treatments for their critically ill loved ones.DesignThis study is a thematic analysis of semi-structured, audio-recorded interviews with primary surrogate decision makers. The codebook included recommended components of SDM and known mechanisms of communication disparities. Analysts were blinded to family member race during coding; then patterns between and within racial groups were analyzed to identify themes.ParticipantsBlack or White primary surrogate decision makers for patients mechanically ventilated for ≥ 48 h.Main MeasuresThemes describing experiences of medical decision making.Key ResultsIn 43 interviews, both Black (n = 25, 58%) and White (n = 18, 42%) family members were middle aged (median [interquartile range, IQR]: 55 [15] years vs 58 [17] years) and had critically ill loved ones with similar lengths of ICU stay (median [IQR]: 18 [22] days vs 23 [18] days). Black family members disproportionately reported the following: (1) experiencing pressure to make decisions that aligned with the ICU team’s recommendations and timeline, (2) needing to code-switch by modifying their communication and behavior to ensure their advocacy was welcomed rather than perceived as intrusive, (3) being disregarded by the medical team, which negatively impacted partnership towards shared decisions, and (4) trusting clinicians’ competence but not necessarily their intentions for critically ill loved ones.ConclusionsCompared to White family members, Black family members of critically ill patients experienced unique challenges relevant to SDM. These results may identify promising focus areas for future conceptual models and interventions to improve equity in ICU-based SDM.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-026-10213-z.

Despite longstanding concern about an increase in use of invasive mechanical ventilation among persons living with dementia (PLWD), no studies have examined trends in mechanical ventilation use among PLWD in Veterans Affairs (VA) facilities. In this study, we aimed to (1) identify recent trends in use of mechanical ventilation among Veteran PLWD and (2) assess mortality trends of those who received mechanical ventilation. In this retrospective national cohort study of all VA medical hospitalizations of Veteran PLWD ≥ 65 years from 2010 to 2019, we used data from the VA Corporate Data Warehouse and defined dementia using a VA-sanctioned list of dementia diagnosis codes. We calculated the percentage of hospitalizations with mechanical ventilation use during the study period and used linear regression to determine a temporal trend. We calculated in-hospital and one-year mortality for hospitalizations of Veteran PLWD involving mechanical ventilation and used linear regression (predictor: time; outcome: mortality) to describe mortality trends. Our cohort included 702,989 hospitalizations at 126 VA medical centers involving 251,545 unique Veteran PLWD. Hospitalized Veteran PLWD were 97.9% male, 89.7% non-Hispanic/Latino, and 72.7% White. Mechanical ventilation use decreased from 1.7% of hospitalizations in 2010 to 1.1% in 2019. Annual in-hospital mortality among those PLWD who received mechanical ventilation decreased from 45.9% in 2010 to 38.0% in 2019 and one-year mortality decreased from 73.4% in 2010 to 70.2% in 2018. The use of mechanical ventilation in hospitalizations of Veteran PLWD was lower than seen in non-VA facilities and decreased from 2010 to 2019. Among hospitalized Veteran PLWD who received mechanical ventilation, in-hospital and one-year mortality remained high throughout the study period but decreased over time. These descriptive mortality decreases may be attributable to patient selection or improved mechanical ventilation practices. Further research should examine patient- and system-level factors to explain observed trends.

BACKGROUND: Rapid qualitative assessment was used to describe early strategies to implement an evidence-based walking program for hospitalized older adults, assiSTed eaRly mobIlity for hospitalizeD older vEterans (STRIDE), mandated by a regional Department of Veterans Affairs health care system office (Veterans Integrated Service Network [VISN]). METHODS: Data were collected from 6 hospital sites via semistructured interviews with key informants, observations of telephone-based technical assistance, and review of VISN-requested program documents (eg, initial implementation plans). An overarching framework of actionable feedback for VISN leadership and specification of locally initiated implementation strategies, using the Expert Recommendations for Implementing Change (ERIC) compilation, was used. Actionable feedback was shared with VISN leadership 1 month after the initiative. RESULTS: ERIC implementation strategies identified were as follows: (1) promoting adaptability-4 sites had physical therapists/kinesiotherapists instead of assistants walk patients; (2) promoting network weaving-strengthening nursing and PT/KT partnership with regular communication opportunities or a point person was important for implementation; (3) distributing educational materials-2 sites distributed information about STRIDE via e-mail and in person; and (4) organizing clinician implementation team meetings-3 sites used interdisciplinary team meetings to communicate with the clinical staff about STRIDE. CONCLUSION: This qualitative study sheds light on early experiences with implementing STRIDE; the results have been instructive for ongoing implementation and future dissemination of STRIDE, and the approach can be applied across contexts to inform implementation of other programs.

The price of a prescription drug can be difficult to determine in the United States. Pricing benchmarks are reference points used to determine acquisition costs as drugs are physically moved through the supply chain, to reimburse pharmacies, to calculate rebates, and to determine patient payments. Public health insurance programs, including Medicare and Medicaid, leverage different pricing benchmarks to pay for drugs for their beneficiaries, and the same drug can vary in price by program. The goal of this primer is to explain the most commonly used drug pricing benchmarks and their current contexts for use.