Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility

Percent of Medicare Enrollees Who Use Home-Based Health Care and Number of Visits Among Respondents to the Medicare Current Beneficiary Survey by Plan Option

Using beneficiary reports of health care utilization from the 2019 Medicare Current Beneficiary Survey Cost Supplement, we compare the prevalence of home-based care and number of visits among Medicare beneficiaries aged 65 and older, by plan option, excluding dual-eligible beneficiaries. Traditional Medicare (TM) beneficiaries were significantly more likely to receive home-based medical visits (10.4% vs. 8.0%) with greater differences observed in vulnerable subgroups. While average number of visits were comparable for TM (35.6) and Medicare Advantage (MA) (34.9) beneficiaries, the distribution of the number of visits varied by plan option. Compared with TM beneficiaries, MA beneficiaries were 4.5 times more likely to receive a single home-based medical visit (17.5% vs. 3.9%) and roughly 1.5 times more likely to have the fewest (two to four visits; 12.2% vs. 8.0%) and greatest number of home visits (90+ visits; 11.1% vs. 7.7%). Access to, and number of, home-based medical care differs significantly by plan option.

Gaps in Primary Care Follow-Up After Hospital Discharge Among Medicare Beneficiaries

BACKGROUND

Timely primary care follow-up after hospitalization is recommended to monitor recovery and coordinate care. Whether follow-up differs for vulnerable populations, such as those with frailty and those discharged to skilled nursing facilities (SNF) prior to returning home, is not known.

METHODS

Retrospective cohort study using a 100% sample of traditional Medicare beneficiaries discharged from hospital to home or from hospital to SNF and then home, between 2010 and 2022. The primary outcome was the receipt of a primary care visit within 30 days of return to home, measured overall and stratified by disposition (discharged home vs. to SNF then home) and by frailty (defined by a claims-based frailty index). Multivariable logistic regression models were used to estimate changes in outcomes over time, overall and stratified by disposition and frailty.

RESULTS

The cohort included 94,248,326 discharges (80.1% age ≥ 65 years, 55.1% female, 36.7% frail) of which 21.5% were discharged to SNF and then home. Between 2010 and 2022, primary care follow-up increased from 51.5% to 57.5% for patients discharged directly home and from 24.3% to 28.4% for patients discharged to SNF then home. In adjusted analyses, compared to those discharged directly home, patients discharged to SNF and then home had an 8.2% point (pp) (95% CI, -8.5 to -7.9) lower predicted probability of ambulatory follow-up in 2022. Among patients discharged directly home, no difference was evident in follow-up between frail and non-frail patients (54.6% vs. 54.1%); difference 0.4 pp (95% CI, -0.1 to 1.0). In contrast, among patients discharged to SNF then home, frail patients had a lower predicted probability of follow-up (42.8% vs. 48.9%); difference - 6.1 pp (95% CI, -7.0 to -5.2).

CONCLUSIONS

Frail patients and patients requiring a short-term SNF stay after hospitalization are less likely to receive timely follow-up upon return to home than other patient groups.

Undocumented Dementia Diagnosis During Skilled Home Health Care: Prevalence and Associated Factors

BACKGROUND

Skilled home health (HH) is a critical source of clinical care for community-living older adults. One-third of HH patients have dementia, but poor information transfer may limit HH providers' awareness of dementia diagnosis. We determined the prevalence of undocumented dementia diagnosis among HH patients and associated care delivery patterns and clinical outcomes.

METHODS

Among a 2018 national sample of Medicare HH patients, we compared those (1) without diagnosed dementia, (2) with dementia documented during HH, (3) with dementia undocumented during HH. Dementia diagnosis was determined from the Medicare Beneficiary Summary File claims-based indicator and documentation was determined via HH clinical assessments (OASIS). We measured HH care delivery and outcomes from claims and assessment data. We fit multivariable negative binomial and logistic regression models to estimate associations of dementia status and documentation with outcomes, while adjusting for patient- and HH agency-level characteristics and clustering at the HH agency level.

RESULTS

Among 1,372,570 HH patients, 30% had diagnosed dementia. Among those with diagnosed dementia, most (69%) had this diagnosis go undocumented during HH. Compared to those with documented dementia, those with undocumented dementia had longer lengths of stay (+3.1 days; 95% CI: 6.4-7.1) and were more likely to receive physical therapy (aOR: 1.19; 95% CI: 1.16-1.22) and less likely to receive social work (aOR: 0.82; 95% CI: 0.80-0.84). Compared to those with documented dementia, those with undocumented dementia had higher odds of hospitalization (aOR: 1.20; 95% CI: 1.17-1.24) and Emergency Department use (aOR: 1.14; 95% CI: 1.11-1.17) and lower odds of discharge to self-care (aOR: 0.88; 95% CI: 0.86-0.90). Findings were robust to sensitivity analyses stratifying by cognitive symptom severity, functional impairment, clinical severity, and referral source.

CONCLUSIONS

Results suggest that HH providers often lack pertinent information regarding patients' dementia status, and patients with undocumented dementia more often experience acute care utilization.

Racial and ethnic disparities in discharge planning among trauma patients in the United States

INTRODUCTION

Trauma patients often require post-discharge services, including home health, nursing care, or inpatient rehabilitation, but disparities may exist.

METHODS

We analyzed the US National Trauma Data Bank (2011-2021). Insured patients that survived to discharge were stratified by race and ethnicity (non-Hispanic White; non-Hispanic Black; Hispanic; non-Hispanic Asian), and propensity score matched based on age, sex, insurance type, Charlson Comorbidity Index, and Injury Severity Score (ISS). An ordered logistic regression was performed on the matched cohorts to estimate the odds ratio of receiving a higher level of discharge services compared to white patients.

RESULTS

We analyzed 7,172,601 patients. Race and ethnicity composition was 72.8 ​% non-Hispanic White, 14.6 ​% non-Hispanic Black, 10.4 ​% Hispanic, and 2.2 ​% non-Hispanic Asian. Compared to White patients, for non-Hispanic Black patients, the odds ratio of a higher level of discharge services was 0.84 (0.84, 0.85); for Hispanic patients, 0.76 (0.75, 0.76); and for non-Hispanic Asian patients, 0.85 (0.84, 0.86).

CONCLUSIONS

In a propensity-matched cohort, all analyzed minority groups had lower odds of receiving a higher level of discharge services than White patients.

The Case for Aggregated Rehabilitation-Relevant Data Across Health Care Systems and Settings

Health care value, quantified as outcome per unit cost, requires knowing which outcomes are influenced by which intervention at what cost. The value of rehabilitation is still largely unknown. Much of the reason for this limited evidence is historically poor standardization and collection of rehabilitation interventions, and objectively measured outcomes across care settings, care providers, and health care systems. The purposeful standardization and aggregation of rehabilitation-relevant data about interventions, cost, and outcomes from routine clinical practices offers potential to understand and improve the value of rehabilitation. This perspective details the critical need for rehabilitation-relevant data that are aggregated across settings, providers, and systems and proposes 3 options to meet this need, including (1) integrating rehabilitation-relevant data into existing research registry databases that are condition specific, (2) adding rehabilitation-relevant data to federally funded research networks, and (3) creating a novel rehabilitation registry database. There must be continued pursuit of discovering which rehabilitation interventions achieve which specific outcomes, in which settings, for which patients, and at what costs. Successfully aggregating rehabilitation-relevant data is critical for generating evidence that answers these key questions about the value of rehabilitation.

Can We Predict 30-Day Readmission After Hip Fracture?

OBJECTIVES

To determine the most common reason for 30-day readmission after hospitalization for hip fractures.

METHODS

DESIGN

A retrospective review.

SETTING

Single academic medical center that includes a Level 1 trauma center.

PATIENT SELECTION CRITERIA

Included were all patients operatively treated for hip fractures (OTA 31) between October 2014 and November 2023. Patients who died during their initial admission were excluded.

OUTCOME MEASURES AND COMPARISONS

Patient demographics, hospital quality measures, outcomes, and readmission within 30 days after discharge for each patient were reviewed. Thirty-day readmission reason was recorded and correlation analysis was performed.

RESULTS

A total of 3032 patients were identified with a mean age of 82.1 years and 70.5% of patients being women. The 30-day readmission cohort was 2.6 years older ( P < 0.001) and 8.8% more male patients ( P = 0.027), had 0.5 higher Charleston comorbidity index ( P < 0.001), 0.3 higher American Society of Anesthesiologists class ( P < 0.001), and were 9.2% less independent at the time of admission ( P = 0.003). Hemiarthroplasty procedure (32.7% vs. 24.1%) was associated with higher 30-day readmission compared with closed percutaneous screw fixation (4.5% vs. 8.8%) and cephalomedullary nail fixation (52.2% vs. 54.4%, P < 0.001). Those readmitted by 30 days developed more major (16.7% vs. 8.0%; P < 0.001) and minor (50.5% vs. 36.4%; P < 0.001) complications during their initial hospitalization and had a 1.5-day longer length of stay during their first admission ( P < 0.001). Those discharged home were less likely to be readmitted within 30 days (20.7% vs. 27.6%, P = 0.008). Multivariate regression revealed increasing American Society of Anesthesiologists class (odds ratio 1.47, P = 0.002) and preinjury ambulatory status (odds ratio 1.42, P = 0.007) was most associated with increased 30-day readmission. The most common reason for readmission was pulmonary complications (17.1% of complications) including acute respiratory failure, chronic obstructive pulmonary disease exacerbation, and pneumonia.

CONCLUSIONS

Thirty-day readmission after hip fracture was associated with older, sicker patients with decreased preinjury ambulation status. Hemiarthroplasty for femoral neck fracture was also associated with readmission. The most common reason for 30-day readmission after hip fracture was pulmonary complications.

LEVEL OF EVIDENCE

Prognostic Level III. See instructions for authors for a complete description of levels of evidence.

Disparities in Infection Risk Among Home Health Care Patients: A Study Using Area Deprivation Index

OBJECTIVE

To examine the association between neighborhood deprivation and infection-related hospitalizations among home health care (HHC) patients across different rurality levels.

DESIGN

Retrospective observation analysis of 2019 national data sets, including Medicare data linked to 2019 Area Deprivation Index (ADI) data and Rural-Urban Continuum Codes (RUCCs).

SETTING AND PARTICIPANTS

The sample includes 3,656,810 HHC patients from 8135 HHC agencies nationwide. Patients were predominantly White (77.6%), with an average age of 80 years, and mostly female (61.7%). The sample included 24% dual-eligible patients and those living in large metropolitan (53.8%), small metro (30.2%), rural adjacent (11.4%), and remote rural areas (4.6%).

METHODS

Hospital admissions due to infection were identified through International Classification of Diseases, Tenth Revision (ICD-10), codes. Neighborhood deprivation was measured by the 2019 ADI. Patients were stratified by RUCC (large metro, small metro, rural adjacent, or remote rural). Within each rurality stratum, ADI quartiles were constructed, with higher quartiles indicating greater neighborhood deprivation. Multivariable logistic regression was conducted, adjusting for multiple-level variables.

RESULTS

As neighborhood deprivation increased, there was a rise in the proportion of dual-eligible, female, Black, and Hispanic patients, whereas the proportion of White patients decreased, especially in rural areas. Rural areas with higher ADI rankings showed lower quality metrics and reduced health care resources. Higher ADI quartiles were significantly associated with increased infection risks after adjusting for covariates, but this was only observed in remote rural areas, not in urban areas.

CONCLUSIONS AND IMPLICATIONS

The findings highlight significant policy and clinical implications for remote rural areas. Policymakers should increase investments in rural health infrastructure, enhance telehealth, improve transportation services, and offer incentives for health care providers to practice in these areas. The nonsignificant association between neighborhood deprivation and infection outcomes in metropolitan areas may stem from the ADI's limited sensitivity to urban contexts, highlighting the need for more nuanced indices that better capture urban socioeconomic challenges.

"Too few, too far away, for what is paid": Consumer voices about the personal assistance worker crisis

BACKGROUND

The growing gap between demand and supply of personal assistance service (PAS) workers presents a significant burden to those who use services. The intensity and duration of hardship is growing, and consumer voices need to be heard and incorporated into the national dialogue.

OBJECTIVE

This paper explores how PAS worker shortages manifest themselves in the daily lives of people with disabilities using or needing PAS services in the United States.

METHODS

We used thematic coding of qualitative data from the 2022 National Survey on Health and Disability. Respondents (n = 330) provided open-ended responses to the prompt "Briefly explain the types of problems or issues you have had finding PAS or support workers."

RESULTS

Three themes emerged regarding consumer perspectives and experiences with worker shortages (1) low pay, few benefits, and undervalued work, (2) demanding working conditions and logistics, and (3) low quality workers. In combination, these themes informed a fourth theme (4) impacts for PAS consumers characterized by substandard care and additional stress and workload for those who direct their own care.

CONCLUSIONS

As a society, we have taken steps to increase opportunities for community living and created policies to uphold choice and independence for people with disabilities. In the absence of an adequate workforce to support these policies, however, we convey an empty promise. Without tangible steps to resolve these problems at the policy level, such as improved worker pay and protections, hope for resolution to these issues remains elusive.

Long-term functional recovery after rib fractures: The impact of frailty

BACKGROUND

Previous studies have shown that patients with rib fractures experience long-term functional limitations. However, the specific predictors of these worse long-term functional limitations remain under-characterized.

METHODS

We conducted a prospective cohort study including patients ≥18 years with an injury severity score ≥9 and isolated chest injury. Patients included had ≥1 rib fracture and were admitted between July 2015 and May 2019 at one of three Level I trauma centers present in our region. We performed stepwise regression analysis to identify predictors of new functional limitations, i.e., limitations that patients developed postinjury in an activity of daily living. Patients were contacted between 5 and 12 months postinjury to inquire about functional limitations. We assessed frailty using the mFI-5 tool, and a score of 1 was considered moderate frailty, while >1 was considered severe frailty.

RESULTS

Among 279 included patients, 74 (26.5%) developed new functional limitations. The majority of patients had a displaced fracture [118 (42.3%)] and ≥3 rib fractures [237 (84.9%)]. A proportion of patients had superior rib fractures [105 (37.6%)], concomitant clavicular, scapular, or sternal fractures [64 (22.9%)], flail chest [37 (13.3%)], moderate frailty [106 (38.0%)], and severe frailty [57 (20.4%)]. Severe frailty and discharge to a skilled nursing facility, rehabilitation facility, or other location as opposed to home were predictors of new functional limitations.

CONCLUSION

In our population, frailty, not injury characteristics, predicted new long-term functional limitations in patients with rib fractures. Frail patients may benefit from additional inpatient and discharge resources for improved long-term outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Pre-injury frailty and clinical care trajectory of older adults with trauma injuries: A retrospective cohort analysis of A large level I US trauma center

BACKGROUND

Pre-injury frailty among older adults with trauma injuries is a predictor of increased morbidity and mortality.

OBJECTIVES

We sought to determine the relationship between frailty status and the care trajectories of older adult patients who underwent frailty screening in the emergency department (ED).

METHODS

Using a retrospective cohort design, we pooled trauma data from a single institutional trauma database from August 2020 to June 2023. We limited the data to adults 65 years and older, who had trauma injuries and frailty screening at ED presentation (N = 2,862). The predictor variable was frailty status, measured as either robust (score 0), pre-frail (score 1-2), or frail (score 3-5) using the FRAIL index. The outcome variables were measures of clinical care trajectory: trauma team activation, inpatient admission, ED discharge, length of hospital stay, in-hospital death, home discharge, and discharge to rehabilitation. We controlled for age, sex, race/ethnicity, health insurance type, body mass index, Charlson Comorbidity Index, injury type and severity, and Glasgow Coma Scale score. We performed multivariable logistic and quantile regressions to measure the influence of frailty on post-trauma care trajectories.

RESULTS

The mean (SD) age of the study population was 80 (8.9) years, and the population was predominantly female (64%) and non-Hispanic White (60%). Compared to those classified as robust, those categorized as frail had 2.5 (95% CI: 1.86-3.23), 3.1 (95% CI: 2.28-4.12), and 0.3 (95% CI: 0.23-0.42) times the adjusted odds of trauma team activation, inpatient admission, and ED discharge, respectively. Also, those classified as frail had significantly longer lengths of hospital stay as well as 3.7 (1.07-12.62), 0.4 (0.28-0.47), and 2.2 (95% CI: 1.71-2.91) times the odds of in-hospital death, home discharge, and discharge to rehabilitation, respectively.

CONCLUSION

Pre-injury frailty is a predictor of clinical care trajectories for older adults with trauma injuries.

Characteristics and Readmission Risks Following Sepsis Discharges to Home

OBJECTIVE

To examine the characteristics and risk factors associated with 30-day readmissions, including the impact of home health care (HHC), among older sepsis survivors transitioning from hospital to home.

RESEARCH DESIGN

Retrospective cohort study of the Medical Information Mart for Intensive Care (MIMIC)-IV data (2008-2019), using generalized estimating equations (GEE) models adjusting for patient sociodemographic and clinical characteristics.

SUBJECTS

Sepsis admission episodes with in-hospital stays, aged over 65, and discharged home with or without HHC were included.

MEASURES

The outcome was all-cause hospital readmission within 30 days following sepsis hospitalization. Covariates, including the primary predictor (HHC vs. Home discharges), were collected during hospital stays.

RESULTS

Among 9115 sepsis admissions involving 6822 patients discharged home (66.8% HHC, 33.2% Home), HHC patients, compared with those discharged without services, were older, had more comorbidities, longer hospital stays, more prior hospitalizations, more intensive care unit admissions, and higher rates of septic shock diagnoses. Despite higher illness severity in the HHC discharges, both groups had high 30-day readmission rates (30.2% HHC, 25.2% Home). GEE analyses revealed 14% higher odds of 30-day readmission for HHC discharges after adjusting for risk factors (aOR: 1.14; 95% CI: 1.02-1.27; P=0.02).

CONCLUSIONS

HHC discharges experienced higher 30-day readmission rates than those without, indicating the need for specialized care in HHC settings for sepsis survivors due to their complex health care needs. Attention to sepsis survivors, regardless of HHC receipt, is crucial given the high readmission rates in both groups. Further research is needed to optimize postacute care/interventions for older sepsis survivors.

Elevated care at home: An alternative to traditional levels of care

BACKGROUND

Elevated care at home (ECH) is a novel in-home care model supporting early hospital discharge and providing an alternative to institutional postacute care.

OBJECTIVES

This study compares patient characteristics, mortality, and readmission outcomes of hospitalized patients who transitioned to ECH to patients who transitioned to skilled nursing facilities (SNF) and skilled home health services (SHH).

METHODS

A retrospective study of patients between May 2020 and January 2022 transitioned from the hospital to ECH, SNF, or SHH. The analysis compared patient characteristics, 30-day mortality, and readmission stratified by COVID-19 infection status. Outcomes were assessed using logistic regression after propensity score matching.

RESULTS

Of 32,132 eligible patients, 6.3% were transitioned to ECH, 39.7% to SNF, and 54.0% to SHH. After matching, all baseline characteristics except for age were balanced between groups. Postmatch and adjusting for age differences, ECH patients experienced lower risk of death compared to SNF (adjusted odds ratio [AOR] 0.61, 95% confidence interval [CI] 0.40, 0.92) and similar risk of hospital readmission compared to SNF patients (AOR 1.08, 95% CI 0.89, 1.31) and SHH patients (AOR 0.96, 95% CI 0.80, 1.16). COVID-19-negative ECH patients compared to matched SNF patients were more likely to readmit (AOR 1.30, 95% CI 1.02, 1.65) with no significant difference in risk of mortality (AOR 0.72, 95% CI 0.44, 1.18).

CONCLUSIONS

ECH had similar or improved outcomes relative to SNF and SHH. COVID-19-negative ECH patients experienced higher readmissions relative to SNF. ECH supported patients to return home from the hospital and provided an alternative to an institutional postacute setting.

Changes in skilled nursing and home health admissions associated with Medicare payment reforms and the COVID-19 pandemic

BACKGROUND

Shortly after Medicare implemented post-acute care payment reforms, the COVID-19 pandemic began, but little is known about how these reforms and the pandemic impacted admissions to the most common post-acute settings-skilled nursing facilities (SNF) and home health agencies (HHAs)-for the full Medicare fee-for-service population.

METHODS

Using 100% of Medicare fee-for-service data, we conducted adjusted interrupted time series analyses of 31,730,994 hospital stays of all adult beneficiaries discharged alive from the hospital between 2018 and 2021 to examine whether payment reforms and the pandemic were associated with differences in admissions to SNFs and HHAs compared to pre-reform and pre-COVID (baseline) trends.

RESULTS

At baseline, an average 18.0% of hospitalized beneficiaries were admitted to SNFs and 14.8% to HHAs. While SNF payment reform in October 2019 was associated with an immediate reduction in SNF admissions, a positive temporal trend reversed this decrease in admissions. HHA payment reform implemented in January 2020 was associated with increased HHA admissions compared to baseline. Post-COVID, admissions to SNF declined to 15.5% of patients being discharged from hospitals and HHA admissions increased to 19.2%.

CONCLUSIONS

SNF and HHA payment reforms were associated with small increases in admissions to their respective settings, suggesting that Medicare reforms did not negatively impact access. However, the baseline trends of decreasing admissions to SNF and increasing HHA admissions were greatly accelerated by the COVID-19 pandemic. Results highlight changes in the demand for these settings, which must be recognized in policy efforts and research examining impacts on specific patient populations.

The Importance of Quality of Home Health Agencies for Patients in Socioeconomically Disadvantaged Neighborhoods

OBJECTIVES

This study investigated the role of patients' neighborhood socioeconomic status (SES) on the relationship between home health agency (HHA) care quality and health outcomes among home health care patients.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We mainly used 2019 Outcome and Assessment Information Set data, Area Deprivation Index, and Quality of Patient Care Star Rating. We included Medicare beneficiaries (aged ≥ 65 years) who received home health care.

METHODS

We used linear probability regression models to examine whether patients' neighborhood SES moderates the association between care quality of HHAs and health outcomes for 1,657,133 home health care patients.

RESULTS

Our findings show that patients in neighborhoods with lower SES were more likely to use low-quality HHAs (lease disadvantaged neighborhoods: 11%, most disadvantaged neighborhoods: 15.2%). Our main model, adjusted by patient- and HHA-level characteristics, reveals patients living in socioeconomically disadvantaged neighborhoods (less disadvantaged: coefficient: -0.017, P < .001; more disadvantaged: coefficient: -0.035, P < .001; most disadvantaged: coefficient: -0.06, P < .001) and receiving care from low-quality HHAs (average-quality HHAs: coefficient: 0.037, P < .001; high-quality HHAs: coefficient: 0.062, P < .001) were less likely to remain in the community during their home health care. Furthermore, our study highlights that patients in the most disadvantaged neighborhoods encounter additional challenges in remaining at their homes and communities when they use low-quality HHAs.

CONCLUSIONS AND IMPLICATIONS

These findings highlight the need for targeted interventions and policy initiatives aimed at addressing disparities in care quality based on neighborhood SES. Efforts directed at enhancing the quality of care provided by HHAs and access to high-quality HHAs in socioeconomically disadvantaged neighborhoods could substantially impact health equity and outcomes for individuals in these settings.

Setting of initiation and factors associated with antidepressant use on entry to long-term care facilities

AIMS

Antidepressant use increases around long-term care facility (LTCF) entry, and initiation during hospitalizations may contribute to this. This study characterized the care setting (i.e., community-based, hospital or LTCF) where antidepressants were initiated and determined associated resident characteristics.

METHODS

A cross-sectional study including non-Indigenous individuals aged 65-105 years who entered LTCFs in two Australian states during 2015-2019, and were dispensed an antidepressant within 2 months, was conducted. Care settings (community-based, hospital or LTCF) were determined from linked LTCF records, and hospitalizations ≤30 days before LTCF entry. Pharmaceutical claims before and after LTCF entry were screened to determine antidepressant initiation. Multivariate multinomial logistic regression estimated adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for resident characteristics associated with care settings of antidepressant initiation.

RESULTS

This study included 34 525 residents from 1046 LTCFs. Overall, 27 160 (78.7%) commenced antidepressants prior to entry, 2552 (7.4%) in hospital and 4813 (13.9%) in LTCFs. Mirtazapine constituted 44.8% (n = 1143) of antidepressants initiated in hospitals and 39.5% (n = 1902) in LTCFs. Residents who were aged ≥90 years were more likely to start an antidepressant in the LTCF compared to community-based settings (aOR = 1.97, 95% CI 1.74-2.23). Residents recently using a psychotropic were more likely to start an antidepressant in community-based settings before LTCF entry, compared to a hospital or LTCF.

CONCLUSIONS

Individuals receiving antidepressants during transition to LTCFs are often already taking antidepressants prior to entry. Future interventions to optimize antidepressant use in LTCFs should consider setting, recency and indication for antidepressant initiation, and ongoing monitoring for safety.

Impact of Elderly Acute Care Discharge Services on Prevention of Rehospitalisation: A Retrospective Cohort Study Using National Health Data from Kita Ward, Tokyo

Introduction

Integrated care poses a significant challenge for healthcare policies in Japan as evaluation of hospital discharge services is limited. This study aimed to elucidate the effects of discharge services for elderly acute-care patients on preventing rehospitalisation.

Methods

A retrospective cohort study was conducted using national health data from Kita Ward, Tokyo. Survival analysis was performed with a Cox proportional hazards model, with readmission hazard ratios (HRs) as the primary endpoint. Subgroup analysis examined interactions between each discharge service category (dummy variable) and readmission.

Results

The study encompassed 6,681 subjects. The Cox model adjusted for age, gender, and complications revealed increased readmission events in the discharge service group (HR = 2.92, 95% CI 2.60-3.27). Subgroup analysis by age and length of hospital stay identified a preventive effect in the 85-year-old group (HR = 0.68, 95% CI 0.49-0.93) and 15-21-day length of stay group (HR = 0.73, 95% CI 0.53-1.01), suggesting that discharge services may inadvertently lower barriers to readmission due to healthcare system influences.

Conclusion

While discharge services may elevate readmission demand, they appear to have a preventive effect for individuals aged 85 and over or with an average length of stay of 15-21 days.

Anterior Cervical Discectomy and Fusion Associated with Increased Home Discharge Rates in Geriatric Patients with Cervical Disc Herniation Compared to Posterior Cervical Decompression and Fusion: A Propensity-Matched Analysis

INTRODUCTION

Cervical disc herniation often necessitates surgery in elderly patients when nonoperative treatments fail. This study compares discharge outcomes of anterior cervical discectomy and fusion (ACDF) vs. posterior cervical decompression and fusion (PCDF) in geriatric patients.

METHODS

A retrospective analysis of 8622 spine surgery patients (January 2008-December 2020) was performed. Geriatric patients (age ≥65) undergoing primary 2-4 level ACDF or PCDF were included. Propensity score matching (1:1) based on age, sex, ethnicity, body mass index, insurance, American Society of Anesthesiologists classification, Elixhauser comorbidity index, preoperative diagnosis, fusion levels, estimated blood loss, intraoperative transfusion, and procedure length was used. Discharge outcomes were dichotomized to home or nonhome.

RESULTS

After matching, 122 patients (ACDF = 61, PCDF = 61) were analyzed. A larger proportion of ACDF patients were discharged home compared to PCDF (84% vs. 64%, P = 0.02). On binary logistic regression, younger age (OR = 0.88 [0.79, 0.98], P = 0.02), male sex (OR = 2.04 [1.79, 3.28], P = 0.001), lower estimated blood loss (OR = 0.99 [0.99, 0.99], P = 0.001), intraoperative transfusion (OR = 0.43 [0.22, 0.92], P = 0.03), and ACDF approach (OR = 4.34 [1.91, 6.77], P = 0.01) were significant predictors of home discharge.

CONCLUSIONS

ACDF in geriatric patients with cervical disc herniation was associated with higher rates of home discharge compared to PCDF. Tailored surgical approaches based on patient demographics may improve recovery outcomes.

Understanding patients' decision to leave hospital care in Ghana: clinical cases and underlying determinants

BACKGROUND

The quality of patient discharge teaching and information influences most patients' readiness for discharge and perceptions of care. Planned patient discharge positively impacts patient health outcomes and post-discharge care management. However, some patients withdraw from care before being formally discharged, often termed discharge against medical advice (DAMA), among other labels. Patient withdrawal from care occurs in some Ghanaian hospitals, yet this phenomenon is understudied. We present clinical cases of this phenomenon in a Ghanaian hospital to understand why patients and their families leave hospital care before formal discharge.

METHODS

Data was obtained through interviews, a focus group, and participant observations from nurses, patients, and caregivers. Thematic analysis and ethnographic case mapping helped us to identify patient discharge types and five DAMA cases.

RESULTS

The underlying factors for discharge in these cases were identified and interpreted. These included health beliefs and cultural norms, costs of care, low health literacy, length of hospital stay and recovery outcomes. Others were social responsibility demands and lack of medical specialists and equipment. A detailed interrogation of the clinical cases and underlying factors revealed the need to reconceptualize discharge against medical advice.

CONCLUSION

We recommend that providers embrace dialogue, cultural competency, and person-centered care and communication in managing patients' decisions respecting discharge. We reason that discharge against medical advice is a quality gap requiring both patient rights and ethical lense to address.

End-of-Life Health Care Service Use and Cost Among Medicare Decedents With Neurodegenerative Diseases

BACKGROUND AND OBJECTIVES

Although neurodegenerative diseases are a leading cause of death, little is known about health care utilization and cost during the end-of-life (EoL) period or how it compares with that of other life-limiting conditions. We aimed to describe and compare resource utilization among US Medicare decedents with neurodegenerative diseases with decedents with cancer.

METHODS

We conducted a retrospective study of Medicare Part A and B beneficiaries with Alzheimer disease (AD), Parkinson disease (PD), or amyotrophic lateral sclerosis (ALS) who died in 2018. Decedents diagnosed with malignant brain tumors or pancreatic cancer served as non-neurodegenerative comparators. Descriptive analyses examined demographic and clinical characteristics in the last year of life. The probabilities and associated costs of emergency department (ED), inpatient, skilled nursing facility (SNF), and hospice utilization during the last 12 and 6 months of life were also compared between persons with neurodegenerative diseases and cancer, adjusting for sociodemographic factors and comorbidity burden.

RESULTS

A total of 1,126,799 Medicare beneficiaries died in 2018, of which 357,926 had a qualifying diagnosis. Persons with neurodegenerative diseases were older and more frequently received Medicaid assistance than persons with brain or pancreatic cancer. In all groups, health care service utilization increased over the last year of life, and total costs were predominantly attributable to inpatient care. In the last 6 months of life, neurologist care was infrequent among patients with neurodegenerative disease (AD: 1.5%; PD: 8.6%; ALS: 32.0%). Persons with neurodegenerative diseases as compared to persons with malignant brain tumors also had greater odds of ED use (AD: adjusted odds ratio [aOR] 1.17, 95% CI 1.11-1.23; PD: aOR 1.18, 95% CI 1.11-1.25; ALS: aOR 1.11, 95% CI 1.01-1.23), lower odds of hospitalization (AD: aOR 0.64, 95% CI 0.60-0.68; PD: aOR 0.65, 95% CI 0.61-0.69; ALS: aOR 0.33, 95% CI 0.30-0.37), and lower odds of hospice enrollment (AD: aOR 0.33, 95% CI 0.31-0.36; PD: aOR 0.33, 95% CI 0.31-0.36; ALS: aOR 0.41, 95% CI 0.36-0.46). The findings were similar in pancreatic cancer.

DISCUSSION

Persons with neurodegenerative diseases in the United States are more likely to visit the ED and less likely to use inpatient and hospice services at EoL than persons with brain or pancreatic cancer. These group differences may stem from prognostic uncertainty and reflect inadequate EoL care practices, requiring further investigation to ensure more timely palliative care and hospice referrals.

Home Health Care and Place of Death in Medicare Beneficiaries With and Without Dementia

BACKGROUND AND OBJECTIVES

Home health care supports patient goals for aging in place. Our objective was to determine if home health care use in the last 3 years of life reduces the risk of inpatient death without hospice.

RESEARCH DESIGN AND METHODS

We analyzed the characteristics of 2,065,300 Medicare beneficiaries who died in 2019 and conducted multinomial logistic regression analyses to evaluate the association between the use and timing of home health care, dementia diagnosis, and place of death.

RESULTS

Receiving any home health care in the last 3 years of life was associated with a lower probability of inpatient death without hospice (Pr 23.3% vs 31.5%, p < .001), and this effect was stronger when home health care began prior to versus during the last year of life (Pr 22.5% vs 24.3%, p < .001). Among all decedents, the probability of death at home with hospice compared to inpatient death with hospice was greater when any home health care was used (Pr 46.0% vs 36.5%, p < .001), and this association was strongest among beneficiaries with dementia who started home health care at least 1 year prior to death (Pr 55.6%, p < .001).

DISCUSSION AND IMPLICATIONS

Use of home health care during the last 3 years of life was associated with reduced rates of inpatient death without hospice, and increased rates of home death with hospice. Increasing affordable access to home health care can positively affect end-of-life care outcomes for older Americans and their family caregivers, especially those with dementia.

The 2023 Update on Pressure Injuries: A Review of the Literature

GENERAL PURPOSE

To provide a summary of six articles published in 2023 that provide important new data or insights about pressure injuries (PIs).

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Summarize selected current evidence addressing the prevention of PIs.2. Evaluate new studies exploring PI treatment modalities.3. Identify recent findings concerning the role of artificial intelligence in staging PIs.

Exploring Predictors of Long-Term Care Facility Admissions in Stroke Survivors: Insights from a Taiwanese Hospital-Based Study

Purpose

Acute stroke significantly increases the risk of long-term care facility (LTCF) admission, due to sudden functional impairments. This study aims to identify risk factors associated with LTCF admission among stroke patients, specifically targeting those who transitioned from independence to disability after stroke.

Patients and Methods

We retrospectively enrolled 2027 stroke patients admitted between 2017 and 2022 from the Chi Mei Medical Center's stroke registry in Southern Taiwan, focusing on those with pre-stroke modified Rankin Scale (mRS) scores ≤ 2 and post-stroke mRS scores ≥ 3. Patients were categorized into LTCF and non-LTCF groups. Stroke severity, comorbidities, and discharge outcomes were evaluated, using logistic regression analyses to identify LTCF admission risk factors.

Results

Of the 2027 patients, 343 (16.9%) were admitted to LTCFs post-discharge. The LTCF group exhibited higher discharge mRS and National Institute of Health Stroke Scale scores, and lower Barthel Index scores. Factors linked to LTCF admission included higher discharge mRS scores, lower Barthel Index scores, nasogastric tube placement at discharge, and longer hospital stays. Barthel Index scores showed no significant change from admission to discharge in the LTCF group.

Conclusion

Stroke severity, post-stroke functional status and nasogastric tube placement are significant predictors of LTCF admission in stroke patients. Early recognition of these factors is crucial for effective discharge planning and reducing the need for institutionalization. The study emphasizes the need for personalized interventions targeting these risk factors to improve patient outcomes and optimize medical resource utilization.

Patterns of national emergency department utilization by fee-for-service Medicare beneficiaries with dementia

BACKGROUND

Individuals with Alzheimer's disease and related dementias (ADRD) often face high acute care clinical utilization and costs with unclear benefits in survival or quality of life. The emergency department (ED) is frequently the site of pivotal decisions in these acute care episodes. This study uses national Medicare data to explore this population's ED utilization.

METHODS

Retrospective cohort study of persons aged ≥66 years enrolled in traditional Medicare with a Chronic Condition Warehouse diagnosis of dementia. Primary 1-year outcome measures included ED visits with and without hospitalization, ED visits per 100 days alive, and health-care costs. A multivariate random effects regression model (clustered by county of residence), adjusted for sociodemographics and comorbidities, examined how place of care on January 1, 2018, was associated with subsequent ED utilization.

RESULTS

In 2018, 2,680,006 ADRD traditional Medicare patients (mean age 82.9, 64.2% female, 9.4% Black, 6.2% Hispanic) experienced a total of 3,234,767 ED visits. Over half (52.2%) of the cohort experienced one ED visit, 15.5% experienced three or more, and 37.1% of ED visits resulted in hospitalization. Compared with ADRD patients residing at home without services, the marginal difference in ED visits per 100 days alive varied by location of care. Highest differences were observed for those with hospitalizations (0.48 visits per 100 days alive, 95% confidence interval [CI] 0.47-0.49), skilled nursing facility (rehab/skilled nursing facility [SNF]) stays (0.27, 95% CI 0.27-0.28), home health stays (0.25, 95% CI 0.25-0.26), or observation stays (0.82, 95% CI 0.77-0.87). Similar patterns were observed with ED use without hospitalization and health-care costs.

CONCLUSIONS

Persons with ADRD frequently use the ED-particularly those with recent hospitalizations, rehab/SNF stays, or home health use-and may benefit from targeted interventions during or before the ED encounters to reduce avoidable utilization and ensure goal-concordant care.

Social Disparities and Critical Illness during the Coronavirus Disease 2019 Pandemic: A Narrative Review

The coronavirus disease 2019 (COVID-19) pandemic raised new considerations for social disparities in critical illness including hospital capacity and access to personal protective equipment, access to evolving therapies, vaccinations, virtual care, and restrictions on family visitation. This narrative review aims to explore evidence about racial/ethnic and socioeconomic differences in critical illness during the COVID-19 pandemic, factors driving those differences and promising solutions for mitigating inequities in the future. We apply a patient journey framework to identify social disparities at various stages before, during, and after patient interactions with critical care services and discuss recommendations for policy and practice.

The role of Medicaid home- and community-based services in use of Medicare post-acute care

OBJECTIVE

Medicaid-funded long-term services and supports are increasingly provided through home- and community-based services (HCBS) to promote continued community living. While an emerging body of evidence examines the direct benefits and costs of HCBS, there may also be unexplored synergies with Medicare-funded post-acute care (PAC). This study aimed to provide empirical evidence on how the use of Medicaid HCBS influences Medicare PAC utilization among the dually enrolled.

DATA SOURCES

National Medicare claims, Medicaid claims, nursing home assessment data, and home health assessment data from 2016 to 2018.

STUDY DESIGN

We estimated the relationship between prior Medicaid HCBS use and PAC (skilled nursing facilities [SNF] or home health) utilization in a national sample of duals with qualifying index hospitalizations. We used inverse probability weights to create balanced samples on observed characteristics and estimated multivariable regression with hospital fixed effects and extensive controls. We also conducted stratified analyses for key subgroups.

DATA EXTRACTION METHODS

The primary sample included 887,598 hospital discharges from community-dwelling duals who had an eligible index hospitalization between April 1, 2016, and September 30, 2018.

PRINCIPAL FINDINGS

We found HCBS use was associated with a 9 percentage-point increase in the use of home health relative to SNF, conditional on using PAC, and a meaningful reduction in length of stay for those using SNF. In addition, in our primary sample, we found HCBS use to be associated with an overall increase in PAC use, given that the absolute increase in home health use was larger than the absolute decrease in SNF use. In other words, the use of Medicaid-funded HCBS was associated with a shift in Medicare-funded PAC use toward home-based settings.

CONCLUSION

Our findings indicate potential synergies between Medicaid-funded HCBS and increased use of home-based PAC, suggesting policymakers should cautiously consider these dynamics in HCBS expansion efforts.

Risk Categories for Discharge Planning Using AM-PAC "6-Clicks" Basic Mobility Scores in Non-Surgical Hospitalized Adults

BACKGROUND

 Early discharge planning is important for safe, cost-effective, and timely hospital discharges. Patients with deconditioning are at risk for prolonged lengths of stay related to discharge needs. Functional mobility outcome measures are associated with discharge disposition. The purpose of this study is to examine the clinical usefulness of risk categories based on the Activity Measure for Post-Acute Care (AM-PAC) "6-clicks" Basic Mobility (6cBM) scores on predicting discharge destination.

METHODS

A retrospective cohort study of 3739 adults admitted to general medical units at an urban, academic hospital between January 1, 2018 and February 29, 2020 who received at least two physical therapy visits and had an AM-PAC 6cBM recorded within 48 hours of admission and before discharge. The outcome variable was discharge destination dichotomized to post-acute care facilities (PACF); inpatient rehabilitation, skilled nursing facility, or subacute rehabilitation) or home (with or without home care services). The predictor variables were 6cBM near admission and discharge. Logistic regression was used to estimate the odds of being discharged to PACF compared to home, based on the Three-level risk categorization system: (a) low (6cBM score > 20), (b) moderate (6cBM score 15-19), or (c) high (6cBM score < 14) risk.

RESULTS

Analysis indicated important differences between the three risk categories in both time periods. Based on 6cBM at admission, patients in the high-risk category were nine times more likely to be discharged to PACF than those in the low-risk category. At discharge, those in the high-risk category were 29 times more likely to go to PACF than those in the low-risk category. Other characteristics differentiating patients who went to PACF were sex (males), age (older) and longer hospitalization.

CONCLUSIONS

Predicting risk for discharge to a PACF using risk categories based on AM-PAC 6cBM can be useful for early discharge planning.

Impact of Interprofessional Collaborative Practice on Functional Improvements Among Post-Acute Stroke Survivors: A Retrospective Cross-Sectional Study

Background

Stroke survivors in post-acute care frequently experience physiological dysfunction and reduced quality of life. This study aims to assess the impact of the Post-Acute Care Interprofessional Collaborative Practice (PAC-IPCP) program across different care settings, and to identify sensitive tools for assessing physiological functions among post-acute stroke survivors.

Methods

This retrospective study involved 210 stroke survivors in Taiwan. Participants who self-selection for their preferred between hospital care setting and home care setting under PAC-IPCP. Multiple assessment tools were utilized, including the Barthel Index (BI), Functional Oral Intake Scale (FOIS), Mini Nutritional Assessment (MNA), EQ-5D-3L, and Instrumental Activities of Daily Living (IADL). The logistic regression was used to estimate the odds ratios of various functional assessment tools between hospital and home care settings. Additionally, the area under the ROC curves was used to determine which functional assessment tools had higher accuracy in measuring the association between care settings.

Results

Of the study population, 138 stroke survivors (65.71%) selection hospital care setting and 72 stroke survivors (34.29%) selection home care setting. The PAC-IPCP program was equally effective in both care settings for physical function status and quality of life improvements. Specifically, the BI emerged as the most sensitive tool for assessing care settings, with an adjusted OR of 1.04 (95% CI:1.02-1.07, p < 0.0001; AUC = 0.7557). IPCP-based hospital and home care models are equally effective in facilitating improved functional outcomes in post-acute stroke survivors.

Conclusion

The PAC-IPCP program is versatile and effective across care settings. The BI stands out as a robust assessment tool for physiological functions, endorsing its broader clinical application. Future studies should also consider swallowing and nutritional status for a more holistic approach to rehabilitation.

Potential US Health Care Savings Based on Clinician Views of Feasible Site-of-Care Shifts

Importance

Shifting care to alternative sites when clinically appropriate may be associated with reduced US health care spending, improved access, and, in some cases, improved care outcomes.

Objective

To fill 2 main gaps in the current literature on site-of-care shifts: (1) understanding the clinician perspective on appropriateness of alternative care sites, given the central role they play in referrals and patient trust and (2) considering all potential sites where care could shift and calculating net savings potential.

Design, Setting, and Participants

In this survey study, physicians (MDs and DOs), nurse practitioners, physician assistants, nurse anesthetists, radiology and imaging technicians, and psychologists were surveyed from September 17 to November 22, 2021, about potential shifts of care from the hospital setting to alternative sites. Participants were selected by the survey firm Intellisurvey to provide broad representation across all specialties of interest. A minimum of 34 clinicians responded to each question. Data were analyzed from April 2022 through October 2023.

Exposure

More than 5000 individual diagnostic and procedural codes were reviewed and sorted into 312 distinct care activities by an expert panel of physicians. Survey respondents were then provided with the 2019 claims-based distribution across sites of care for each care activity and were asked, "based on your clinical judgment, what portion of [care activity] could safely occur in each of the following sites of care, without compromising clinical outcomes?"

Main Outcomes and Measures

Based on clinician-reported distributions, the total potential shift of volume from hospital-based settings to alternative sites and the associated net savings were estimated.

Results

Survey respondents included 1069 practicing clinicians (386 female [36.1%]; mean [SD] years since residency of physicians, 21.0 [9.7] years; mean [SD] age of nonphysicians, 45.3 [9.4] years) across specialties, all of whom practiced more than 20 clinical hours per week. There were 794 physicians (74.3%), and the remaining 275 respondents were midlevel professionals, such as physician assistants. Among 312 care activities surveyed, respondents indicated that 10.3 percentage points (95% CI, 10.0-10.5 percentage points) of commercial and 10.9 percentage points (95% CI, 10.7-11.1 percentage points) of Medicare volume currently taking place in hospital-based settings could shift to alternative sites with today's technology without compromising clinical outcomes. Across the entire US health care system, these shifts could be associated with a reduction in overall health care consumption spending ($3 562 339 000 000 000) by approximately $113.8 billion ($113 767 446 087 174 [3.2%]) to $147.7 billion ($147 661 672 284 263 [4.1%]) annually.

Conclusions and relevance

In this study, a substantial net savings opportunity was estimated. However, realizing this potential will require ongoing alignment among organizations, clinicians, and policymakers to overcome barriers to these shifts.

Challenges related to transitioning from hospital to temporary care at a skilled nursing facility: a descriptive study

PURPOSE

With decreasing number of hospital beds, more citizens are discharged to temporary care at skilled nursing facilities, requiring increasingly complex care in a non-hospital setting. We mapped challenges related to the transition of citizens from hospital to temporary care at a skilled nursing facility in relation to medication management, responsibility of medical treatment, and communication.

METHODS

Descriptive study of citizens discharged from Odense University Hospital to temporary care from May 2022 to March 2023.

RESULTS

We included 209 citizens (53% women, median age 81 years). Most citizens (97%; n = 109/112) had their medication changed during hospital admission. Citizens used a median of eight medications, including risk medications (96%, n = 108). Medication-related challenges occurred for 37% (n = 77) of citizens and most often concerned missing alignment of medication records. Half of citizens (47%, n = 99) moved into temporary care with all medication needed for further dispensing. Nurses conducted in median three telephone calls (interquartile range [IQR 1-4]) and sent in median two correspondences (IQR 1-3) per citizen within the first 5 days. Nurses most often called the hospital physician (41% of telephone calls, n = 265/643) and sent correspondences to the general practitioner (55% of correspondences, n = 257/469). For 31% (n = 29/95) of citizens requiring action from nursing staff, this could have been avoided if the nurses had had access to the discharge letter.

CONCLUSION

We identified several challenges related to the transition of patients from hospital to temporary care, most often related to medication. A third of actions related to medication management were considered avoidable with improved practices around communication.

Where Patients Live Matter in Emergency Department Visits in Home Health Care: Rural/Urban Status and Neighborhood Socioeconomic Status

An increasing body of evidence highlights the importance of an individual's place of residence on their health and functional outcomes. This study is based on Outcome and Assessment Information Set data to assess the differences in emergency department visits among Medicare home health care patients by patients' residence location (rural/urban status and neighborhood socioeconomic status). Compared to urban patients, a disproportionately higher proportion of rural patients lived in more or most disadvantaged neighborhoods (83.9% vs. 41.3%). Using linear probability regression models, patients in rural areas (coefficient = .02, p < .001) and disadvantaged neighborhoods (less disadvantaged: coefficient = .02, p < .001; more disadvantaged: coefficient = .034, p < .001; most disadvantaged: coefficient = .042, p < .001) were more likely to experience emergency department visits. Policymakers should consider utilizing area-based target interventions to mitigate gaps in home health care. Also, given that the majority of rural patients reside in disadvantaged neighborhoods, neighborhood characteristics should be considered in addressing rural-urban disparities and improving home health care.

Dynamic Prediction of Post-Acute Care Needs for Hospitalized Medicine Patients

OBJECTIVES

Use patient demographic and clinical characteristics at admission and time-varying in-hospital measures of patient mobility to predict patient post-acute care (PAC) discharge.

DESIGN

Retrospective cohort analysis of electronic medical records.

SETTING AND PARTICIPANTS

Patients admitted to the two participating Hospitals from November 2016 through December 2019 with ≥72 hours in a general medicine service.

METHODS

Discharge location (PAC vs home) was the primary outcome, and 2 time-varying measures of patient mobility, Activity Measure for Post-Acute Care (AM-PAC) Mobility "6-clicks" and Johns Hopkins Highest Level of Mobility, were the primary predictors. Other predictors included demographic and clinical characteristics. For each day of hospitalization, we predicted discharge to PAC using the demographic and clinical characteristics and most recent mobility data within a random forest (RF) for survival, longitudinal, and multivariate (RF-SLAM) data. A regression tree for the daily predicted probabilities of discharge to PAC was constructed to represent a global summary of the RF.

RESULTS

There were 23,090 total patients and compared to PAC, those discharged home were younger (64 vs 71), had shorter length of stay (5 vs 8 days), higher AM-PAC at admission (43 vs 32), and average AM-PAC throughout hospitalization (45 vs 35). AM-PAC was the most important predictor, followed by age, and whether the patient lives alone. The area under the hospital day-specific receiver operating characteristic curve ranged from 0.76 to 0.79 during the first 5 days. The global summary tree explained 75% of the variation in predicted probabilities for PAC from the RF. Sensitivity (75%), specificity (70%), and accuracy (72%) were maximized at a PAC probability threshold of 40%.

CONCLUSIONS AND IMPLICATIONS

Daily assessment of patient mobility should be part of routine practice to help inform care planning by hospital teams. Our prediction model could be used as a valuable tool by multidisciplinary teams in the discharge planning process.

Trends in Patient-Reported Physical Function After Hip Fracture Surgery

Background Hip fractures carry significant morbidity and mortality, yet studies assessing post-surgical functional recovery from the patient's perspective are scarce, lacking benchmarks against age-matched populations. This study aimed to identify factors influencing postoperative functional outcomes, compared to the lower 25th percentile of normal age-matched populations, and to compare postoperative physical function with one-year mortality following hip fracture surgery. Methodology A retrospective review of 214 hip fracture patients reporting to the emergency department (ED) from July 2020 to June 2023 was conducted, with all completing a three-month postoperative Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) survey. Primary outcomes included three-month PROMIS-PF scores, with secondary outcomes focusing on one-year mortality. Factors such as demographics, comorbidities, procedures, time to surgery, length of stay, and postoperative outcomes were analyzed for correlation. Multivariate logistic regression assessed predictors of achieving a PROMIS-PF T-score of at least 32.5, representing the bottom 25th percentile for age-matched populations, and the relationship between three-month PROMIS PF T-scores and one-year mortality. Results Surgery was performed within 24 hours of ED arrival in 118 (55.1%) patients, the average length of stay was 5.2 days, and 64 (29.9%) were discharged home. Total hip arthroplasty and home discharge correlated with higher physical function scores. In contrast, older age, higher American Society of Anesthesiologists scores, certain comorbidities, specific surgical procedures, and longer hospital stays were associated with lower scores. Fewer than half (102 [47.7%]) achieved functional levels comparable to the 25th percentile of age-matched populations. Multivariate analysis indicated chronic obstructive pulmonary disease and home discharge as predictors of achieving this threshold, while higher PROMIS-PF T-scores were associated with reduced one-year mortality. Conclusions Patients undergoing hip fracture surgery are unlikely to achieve high levels of physical function within the three-month postoperative period. Fewer than half of these patients will reach functional levels, and decreased early function is associated with an increased risk of one-year mortality.

Home health care is associated with an increased risk of readmission and cost of care without reducing risk of complication following shoulder arthroplasty: a propensity-score analysis

BACKGROUND

Home health services provide patients with additional professional care and supervision following discharge from the hospital to theoretically reduce the risk of complication and reduce health care utilization. The aim of this investigation was to determine if patients assigned home health services following total shoulder arthroplasty (anatomic [TSA] and reverse [RSA]) exhibited lower rates of medical complications, lower health care utilization, and lower cost of care compared with patients not receiving these services.

METHODS

A national insurance database was retrospectively reviewed to identify all patients undergoing primary TSA and RSA from 2010 to 2019. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home without services. We compared medical complication rates, emergency department (ED) visits, readmissions, and 90-day cost of care between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on all outcomes.

RESULTS

A total of 1119 patients received home health services and were matched to 11,190 patients who were discharged home without services. There was no significant difference in patients who received home health services compared with those who did not receive home health services with respect to rates of ED visits within 30 days (OR 1.293; P = .0328) and 90 days (OR 1.215; P = .0378), whereas the home health group demonstrated increased readmissions within 90 days (OR 1.663; P < .001). For all medical complications, there was no difference between cohorts. Episode-of-care costs for home health patients were higher than those discharged without these services ($12,521.04 vs. $9303.48; P < .001).

CONCLUSION

Patients assigned home health care services exhibited higher cost of care and readmission rates without a reduction in the rate of complication or early return to the ED. These findings suggest that home health care services should be strongly analyzed on a case-by-case basis to determine if a patient may benefit from its implementation.

Development and Validation of the Hospital-to-Home-Health Transition Quality (H3TQ) Index: A Novel Measure to Engage Patients and Home Health Providers in Evaluating Hospital-to-Home Care Transition Quality: A Novel Measure to Engage Patients and Home Health Providers in Evaluating Hospital-to-Home Care Transition Quality

BACKGROUND

Patients requiring skilled home health care (HH) after hospitalization are at high risk of adverse events. Human factors engineering (HFE) approaches can be useful for measure development to optimize hospital-to-home transitions.

OBJECTIVE

To describe the development, initial psychometric validation, and feasibility of the Hospital-to-Home-Health-Transition Quality (H3TQ) Index to identify patient safety risks.

METHODS

Development : A multisite, mixed-methods study at 5 HH agencies in rural and urban sites across the United States. Testing : Prospective H3TQ implementation on older adults' hospital-to-HH transitions. Populations Studied : Older adults and caregivers receiving HH services after hospital discharge, and their HH providers (nurses and rehabilitation therapists).

RESULTS

The H3TQ is a 12-item count of hospital-to-HH transitions best practices for safety that we developed through more than 180 hours of observations and more than 80 hours of interviews. The H3TQ demonstrated feasibility of use, stability, construct validity, and concurrent validity when tested on 75 transitions. The vast majority (70%) of hospital-to-HH transitions had at least one safety issue, and HH providers identified more patient safety threats than did patients/caregivers. The most frequently identified issues were unsafe home environments (32%), medication issues (29%), incomplete information (27%), and patients' lack of general understanding of care plans (27%).

CONCLUSIONS

The H3TQ is a novel measure to assess the quality of hospital-to-HH transitions and proactively identify transitions issues. Patients, caregivers, and HH providers offered valuable perspectives and should be included in safety reporting. Study findings can guide the design of interventions to optimize quality during the high-risk hospital-to-HH transition.

Identifying Racial and Ethnic Disparities in Acute Inpatient Rehabilitation

OBJECTIVE

To investigate whether racial, ethnic, and linguistic disparities exist at discharge from an acute inpatient rehabilitation facility (IRF) by examining change in Functional Independence Measure (FIM) scores and discharge destination.

DESIGN

This is a retrospective study using our IRF's data from the Uniform Data System for Medical Rehabilitation from 2013-2019. FIM scores and discharge destination were compared between race, language, and ethnic groups, with adjustment for patient characteristics.

SETTING

An urban hospital with a level 1 trauma center, comprehensive stroke center, and IRF with Commission on Accreditation of Rehabilitation Facilities (CARF) certification.

PARTICIPANTS

2518 patients admitted to the IRF from 2013-2019 (N=2518).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Change in FIM score and discharge destination.

RESULTS

After adjusting for covariates, non-White patients and patients with limited English proficiency had significantly lower functional recovery, as measured by smaller changes in FIM scores from IRF admission to discharge. Additionally, both groups were more likely to be discharged home with home health care than to a skilled nursing facility, compared with White and English-speaking patients. Disparities in discharge destination persisted within patients with noncommercial insurance (Medicaid or Medicare) and a stroke diagnosis but not within those who had commercial insurance or a nonstroke diagnosis.

CONCLUSIONS

Racial and linguistic disparities were identified within our CARF certified IRF; however, the organization is committed to reducing health care disparities. Next steps will include investigating interventions to reduce disparities.

Factors Predisposing Patients to Nonhome Discharge After Surgery for Degenerative Cervical Myelopathy: A Retrospective Analysis

OBJECTIVE

The objective of this study is to evaluate factors associated with discharge to subacute care after surgery for degenerative cervical myelopathy.

DESIGN

This is a retrospective chart review of adults who underwent cervical spine surgery for degenerative cervical myelopathy between 2014 and 2020 ( N = 135).

RESULTS

Patients discharged to a subacute setting were older (68.1 ± 8.6 vs. 64.1 yrs ± 8.8, P = 0.01), more likely to be unmarried (55.8% vs. 33.7% married, P = 0.01), and more likely to have Medicare or Medicaid (83.7% vs. 65.9% private insurance, P = 0.03) than patients discharged home. A posterior surgical approach was associated with discharge to a subacute setting (62.8% vs. 43.5% anterior approach, P = 0.04). A total of 87.8% of patients discharged to a subacute setting required moderate or maximum assistance for bed mobility versus 26.6% of patients discharged home ( P < 0.0001). Compared with patients discharged home, patients discharged to a subacute setting ambulated a shorter distance in their first physical therapy evaluation after surgery (8.9 ± 35.8 vs. 53.7 ± 61.78 m in the home discharge group, P < 0.0001).

CONCLUSIONS

Analysis of these factors may guide discussions about patient expectations for postoperative discharge placement.

Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up

A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.

Off-Pump Coronary Artery Bypass Grafting Does Not Confer Superior Outcomes Among Frail Patients

Off-pump coronary revascularization (OPCAB) has been proposed to benefit patients who are at a greater surgical risk because it avoids the use of extracorporeal circulation. Although, historically, older patients were considered high-risk candidates, recent studies implicate frailty as a more comprehensive measure of perioperative fitness. Yet, the outcomes of OPCAB in frail patients have not been elucidated. Thus, using a national cohort of frail patients, we assessed the impact of OPCAB relative to on-pump coronary revascularization (ONCAB). Patients who underwent first-time elective coronary revascularization were tabulated from the 2010 to 2020 Nationwide Readmissions Database. Frailty was assessed using the previously-validated Johns Hopkins Adjusted Clinical Groups indicator. Multivariable models were used to consider the independent associations between OPCAB and the key outcomes. Of ∼26,529 frail patients, 6,322 (23.8%) underwent OPCAB. After risk adjustment and compared with ONCAB, OPCAB was linked with similar odds of in-hospital mortality but greater likelihood of postoperative cardiac arrest (adjusted odds ratio [AOR] 1.53, confidence interval [CI] 1.13 to 2.07) and myocardial infarction (AOR 1.44, CI 1.23 to 1.69). OPCAB was further associated with greater odds of postoperative infection (AOR 1.22, CI 1.02 to 1.47) but decreased need for blood transfusion (AOR 0.68, CI 0.60 to 0.77). In addition, OPCAB faced a +0.86-day increase in length of stay (CI 0.21 to 1.51) but similar costs (β $1,610, CI -$1,240 to 4,460) relative to ONCAB. Although OPCAB was associated with no difference in mortality compared with ONCAB, it was linked with greater likelihood of postoperative cardiac arrest and myocardial infarction. Our findings demonstrate that ONCAB remains associated with superior outcomes, even in the growing population of frail patients who underwent coronary revascularization.

Critical care beyond organ support: the importance of geriatric rehabilitation

Very old critically ill patients pose a growing challenge for intensive care. Critical illness and the burden of treatment in the intensive care unit (ICU) can lead to a long-lasting decline of functional and cognitive abilities, especially in very old patients. Multi-complexity and increased vulnerability to stress in these patients may lead to new and worsening disabilities, requiring careful assessment, prevention and rehabilitation. The potential for rehabilitation, which is crucial for optimal functional outcomes, requires a systematic, multi-disciplinary approach and careful long-term planning during and following ICU care. We describe this process and provide recommendations and checklists for comprehensive and timely assessments in the context of transitioning patients from ICU to post-ICU and acute hospital care, and review the barriers to the provision of good functional outcomes.

The Health Care Burden of Hepatic Encephalopathy

Hepatic encephalopathy-a common and debilitating complication of cirrhosis-results in major health care burden on both patients and caregivers through direct and indirect costs. In addition to risk of falls, inability to work and drive, patients with hepatic encephalopathy often require hospital admission (and often readmission), and many require subacute care following hospitalization. The costs and psychological impact of liver transplantation often ensue. As the prevalence of chronic liver disease increases throughout the United States, the health care burden of hepatic encephalopathy will continue to grow.

The association between opioid use disorder and skilled nursing facility acceptances: A multicenter retrospective cohort study

BACKGROUND

Prior single-hospital studies have documented barriers to acceptance that hospitalized patients with opioid use disorder (OUD) face when referred to skilled nursing facilities (SNFs).

OBJECTIVE

To examine the impact of OUD on the number of SNF referrals and the proportion of referrals accepted.

DESIGN, SETTINGS, AND PARTICIPANTS

A retrospective cohort study of hospitalizations with SNF referrals in 2019 at two academic hospitals in Baltimore, MD.

EXPOSURE

OUD status was determined by receipt of medications for OUD during admission, upon discharge, or the presence of a diagnosis code for OUD.

KEY RESULTS

The cohort included 6043 hospitalizations (5440 hospitalizations of patients without OUD and 603 hospitalizations of patients with OUD). Hospitalizations of patients with OUD had more SNF referrals sent (8.9 vs. 5.6, p < .001), had a lower proportion of SNF referrals accepted (31.3% vs. 46.9%, p < .001), and were less likely to be discharged to an SNF (65.6% vs. 70.3%, p = .003). The effect of OUD status on the number of SNF referrals and the proportion of referrals accepted remained significant in multivariable analyses. Our subanalysis showed that reduced acceptances were driven by the hospitalizations of patients discharged without medications for OUD and those receiving methadone. Hospitalizations of patients discharged on buprenorphine were accepted at the same rates as hospitalizations of patients without OUD.

CONCLUSIONS

This multicenter retrospective cohort study found that hospitalizations of patients with OUD had more SNF referrals sent and fewer referrals accepted. Further work is needed to address the limited discharge options for patients with OUD.

Improving Patient Outcomes Using Measures to Increase Discharge Rates to Home

Background Post-acute care (PAC) centers are facilities used for recuperation, rehabilitation, and symptom management in an effort to improve the long-term outcomes of patients. PAC centers include skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals. In the 1990s, Medicare payment reforms significantly increased the discharge rates to PAC centers and subsequently increased the length of stay (LOS) among these patient populations. Over the last several years, there have been national initiatives and multidisciplinary approaches to improve safe discharge rates to home. Multiple studies have shown that patients who are discharged to home have decreased rates of 30-day readmissions, reduced short-term mortality, and an improvement in their activities of daily living.  Objectives This study aimed to investigate how multidisciplinary approaches could improve a single institution's discharge rates to home. In doing so, we aim to lower hospital readmission rates, hospital length of stay, morbidity and mortality rates, and healthcare-associated costs. Methods A retrospective single-institution cohort study was implemented at Jersey Shore University Medical Center (JSUMC). Data from January 2015 to December 2019 served as the control period, compared to the intervention period from January 2020 to January 2024. Patients were either admitted to JSUMC teaching faculty, hospitalists, or "others," which is composed of various medical and surgical subspecialists. Interventions performed to improve home discharge rates can be categorized into the following: physician education, patient education, electronic medical record (EMR) initiatives, accountability, and daily mobility initiatives. All interventions were performed equally across the three patient populations. The primary endpoint was the proportion of patients discharged to home. Results There were 190,699 patients, divided into a pre-intervention group comprising 98,885 individuals and a post-intervention group comprising 91,814 patients. Within the pre-intervention group, the faculty attended to 8,495 patients, hospitalists cared for 39,145 patients, and others managed 51,245 patients. In the post-intervention period, the faculty oversaw 8,014 patients, hospitalists attended to 35,094 patients, and others were responsible for 48,706 patients. After implementing a series of multidisciplinary interventions, there was a significant increase in the proportion of patients discharged home, rising from 74.9% to 80.2% across the entire patient population. Specifically, patients under the care of the faculty experienced a more substantial improvement, with a discharge rate increasing from 73.6% to 84.4%. Similarly, the hospitalists exhibited a rise from 69.4% to 74.3%, and the others demonstrated an increase from 79.3% to 83.7%. All observed changes yielded a p-value < 0.001. Conclusions By deploying a multifaceted strategy that emphasized physician education, patient education, EMR initiatives, accountability measures, and daily mobility, there was a statistically significant increase in the rate of patient discharges to home. These initiatives proved to be cost-effective and led to a tangible reduction in healthcare-associated costs and patient length of stay. Further studies are required to look into the effect on hospital readmission rates and morbidity and mortality rates. The comprehensive approach showcased its potential to optimize patient outcomes.

Perspectives on supporting Veterans' social needs during hospital to home health transitions: findings from the Transitions Nurse Program

BACKGROUND

Veterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans' social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans' social needs during the transition from hospital to home with skilled HHC.

METHODS

Qualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans' hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans' social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery).

RESULTS

We conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs.

CONCLUSIONS

HHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.

Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma

Introduction

As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase.

Research question

To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care.

Materials and methods

We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition.

Results

A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility.

Discussion and conclusions

Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued.

Readability of postoperative discharge instructions is associated with complication rate in companion animals undergoing sterilisation

BACKGROUND

Readability of client communications is a commonly overlooked topic in veterinary medical education. In human medicine, it has been advised that the readability of patient materials should be at USA schooling sixth-grade level or below. We hypothesised that student written discharge instructions would be of an inappropriate readability level, and discharges scored with higher reading grade levels would be associated with more complications.

METHODS

The cohort comprised 149 dogs and cats presenting for sterilisation. The readability of discharge instructions was assessed using the Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) formulas. Records were examined for evidence of postoperative complications.

RESULTS

The mean FRE score of the discharge instructions was 61.97, with 30.87% being classified as 'difficult' or 'fairly difficult', 60.4% as 'standard' and 8.72% as 'fairly easy'. The mean FKGL was 8.64, with 98% being above reading level 6. Overall, there was an association between FKGL and complication occurrence (p = 0.005). Stratification by species demonstrated FRE and FKGL to be associated with complication occurrence in dogs (FRE score, p = 0.038; FKGL, p = 0.002), but not cats (FRE score, p = 0.964; FKGL, p = 0.679).

LIMITATIONS

Due to the retrospective nature of the study, there were difficulties associated with extracting relevant complication information from the medical records.

CONCLUSION

Only 2% of owner-directed discharge instructions were written at readability levels aligning with the recommendations set forth in the human guidelines.

Immigration enforcement and the institutionalization of elderly Americans

This paper examines the relationship between immigration enforcement and institutionalization rates of the elderly. Exploiting the staggered implementation of the Secure Communities (SC) immigration enforcement program across U.S. counties from 2008 through 2014, we show that SC led to a 0.26 percentage points (6.8 percent) increase in the likelihood that Americans aged 65 and above live in an institution. Supportive of supply shocks in the household services market as a central mechanism, we find that the elderly who are most likely to purchase domestic worker services are also the most likely to move into nursing homes following the implementation of SC. Additionally, we find suggestive evidence of significant reductions in the work hours of housekeepers, personal care aides, and home health workers hinting at the critical role of negative supply shocks in occupations that facilitate aging in community.

Differences in Home Health Services and Outcomes Between Traditional Medicare and Medicare Advantage

Importance

Private Medicare Advantage (MA) plans recently surpassed traditional Medicare (TM) in enrollment. However, MA plans are facing scrutiny for burdensome prior authorization and potential rationing of care, including home health. MA beneficiaries are less likely to receive home health, but recent evidence on differences in service intensity and outcomes among home health patients is lacking.

Objective

To examine differences in home health service intensity and patient outcomes between MA and TM.

Design, Setting, and Participants

This cross-sectional study was conducted from January 2019 to December 2022 in 102 home health locations in 19 states and included 178 195 TM and 107 102 MA patients 65 years or older with 2 or fewer 60-day home health episodes. It included a secondary analysis of standardized assessment and visit data. Inverse probability of treatment weighting regression compared service intensity and patient outcomes between MA and TM episodes, accounting for differences in demographic characteristics, medical complexity, functional and cognitive impairments, social environment, caregiver support, and local community factors. Models included office location, year, and reimbursement policy fixed effects. Data were analyzed between September 2023 and July 2024.

Exposure

TM vs MA plan.

Main Outcomes and Measures

Home health length of stay and number of visits from nursing, physical, occupational, and speech therapy, social work, and home health aides. Patient outcomes included improvement in self-care and mobility function, discharge to the community, and transfer to an inpatient facility during home health.

Results

Of 285 297 total patients, 180 283 (63.2%) were female; 586 (0.2%) were American Indian/Alaska Native, 8957 (3.1%) Asian, 28 694 (10.1%) Black, 7406 (2.6%) Hispanic, 1959 (0.7%) Native Hawaiian/Pacific Islander, 237 017 (83.1%) non-Hispanic White, and 678 (0.2%) multiracial individuals. MA patients had shorter home health length of stay by 1.62 days (95% CI, -1.82 to 1.42) and received fewer visits from all disciplines except social work. There were no differences in inpatient transfers. MA patients had 3% and 4% lower adjusted odds of improving in mobility and self-care, respectively (mobility odds ratio [OR], 0.97; 95% CI, 0.94-0.99; self-care OR, 0.96; 95% CI, 0.92-0.99). MA patients were 5% more likely to discharge to the community compared with TM (OR, 1.05; 95% CI, 1.01-1.08).

Conclusions and Relevance

The results of this cross-sectional study suggest that MA patients receive shorter and less intensive home health care vs TM patients with similar needs. Differences may be due to the administrative burden and cost-limiting incentives of MA plans. MA patients experienced slightly worse functional outcomes but were more likely to discharge to the community, which may have negative implications for MA patients, including reduced functional independence or increased caregiver burden.

Variation in Home Healthcare Use by Dementia Status Among a National Cohort of Older Adults

BACKGROUND

Medicare-funded home healthcare (HHC) delivers skilled nursing, therapy, and related services through visits to the patient's home. Nearly one-third (31%) of HHC patients have diagnosed dementia, but little is currently known regarding how HHC utilization and care delivery differ for persons living with dementia (PLwD).

METHODS

We drew on linked 2012-2018 Health and Retirement Study and Medicare claims for a national cohort of 1 940 community-living older adults. We described differences in HHC admission, length of stay, and referral source by patient dementia status and used weighted, multivariable logistic and negative binomial models to estimate the relationship between dementia and HHC visit type and intensity while adjusting for sociodemographic characteristics, health and functional status, and geographic/community factors.

RESULTS

PLwD had twice the odds of using HHC during a 2-year observation period, compared to those without dementia (odds ratio [OR]: 2.03; p < .001). They were more likely to be referred to HHC without a preceding hospitalization (49.4% vs 32.1%; p < .001) and incurred a greater number of HHC episodes (1.4 vs 1.0; p < .001) and a longer median HHC length of stay (55.8 days vs 40.0 days; p < .001). Among post-acute HHC patients, PLwD had twice the odds of receiving social work services (unadjusted odds ratio [aOR]: 2.15; p = .008) and 3 times the odds of receiving speech-language pathology services (aOR: 2.92; p = .002).

CONCLUSIONS

Findings highlight HHC's importance as a care setting for community-living PLwD and indicate the need to identify care delivery patterns associated with positive outcomes for PLwD and design tailored HHC clinical pathways for this patient subpopulation.

It is not all black and white: The effect of increasing severity of frailty on outcomes of geriatric trauma patients

BACKGROUND

Frailty is associated with poor outcomes in trauma patients. However, the spectrum of physiologic deficits, once a patient is identified as frail, is unknown. The aim of this study was to assess the dynamic association between increasing frailty and outcomes among frail geriatric trauma patients.

METHODS

This is a secondary analysis of the American Association of Surgery for Trauma Frailty Multi-institutional Trial. Patients 65 years or older presenting to one of the 17 trauma centers over 3 years (2019-2022) were included. Frailty was assessed within 24 hours of presentation using the Trauma-Specific Frailty Index (TSFI) questionnaire. Patients were stratified by TSFI score into six groups: nonfrail (<0.12), Grade I (0.12-0.19), Grade II (0.20-0.29), Grade III (0.30-0.39), Grade IV (0.40-0.49), and Grade V (0.50-1). Our Outcomes included in-hospital and 3-month postdischarge mortality, major complications, readmissions, and fall recurrence. Multivariable regression analyses were performed.

RESULTS

There were 1,321 patients identified. The mean (SD) age was 77 years (8.6 years) and 49% were males. Median [interquartile range] Injury Severity Score was 9 [5-13] and 69% presented after a low-level fall. Overall, 14% developed major complications and 5% died during the index admission. Among survivors, 1,116 patients had a complete follow-up, 16% were readmitted within 3 months, 6% had a fall recurrence, 7% had a complication, and 2% died within 3 months postdischarge. On multivariable regression, every 0.1 increase in the TSFI score was independently associated with higher odds of index-admission mortality and major complications, and 3 months postdischarge mortality, readmissions, major complications, and fall recurrence.

CONCLUSION

The frailty syndrome goes beyond a binary stratification of patients into nonfrail and frail and should be considered as a spectrum of increasing vulnerability to poor outcomes. Frailty scoring can be used in developing guidelines, patient management, prognostication, and care discussions with patients and their families.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.