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Scharp D, Hobensack M, Davoudi A, Topaz M. Natural Language Processing Applied to Clinical Documentation in Post-acute Care Settings: A Scoping Review. J Am Med Dir Assoc 2024; 25:69-83. [PMID: 37838000 PMCID: PMC10792659 DOI: 10.1016/j.jamda.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVES To determine the scope of the application of natural language processing to free-text clinical notes in post-acute care and provide a foundation for future natural language processing-based research in these settings. DESIGN Scoping review; reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. SETTING AND PARTICIPANTS Post-acute care (ie, home health care, long-term care, skilled nursing facilities, and inpatient rehabilitation facilities). METHODS PubMed, Cumulative Index of Nursing and Allied Health Literature, and Embase were searched in February 2023. Eligible studies had quantitative designs that used natural language processing applied to clinical documentation in post-acute care settings. The quality of each study was appraised. RESULTS Twenty-one studies were included. Almost all studies were conducted in home health care settings. Most studies extracted data from electronic health records to examine the risk for negative outcomes, including acute care utilization, medication errors, and suicide mortality. About half of the studies did not report age, sex, race, or ethnicity data or use standardized terminologies. Only 8 studies included variables from socio-behavioral domains. Most studies fulfilled all quality appraisal indicators. CONCLUSIONS AND IMPLICATIONS The application of natural language processing is nascent in post-acute care settings. Future research should apply natural language processing using standardized terminologies to leverage free-text clinical notes in post-acute care to promote timely, comprehensive, and equitable care. Natural language processing could be integrated with predictive models to help identify patients who are at risk of negative outcomes. Future research should incorporate socio-behavioral determinants and diverse samples to improve health equity in informatics tools.
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Affiliation(s)
| | | | - Anahita Davoudi
- VNS Health, Center for Home Care Policy & Research, New York, NY, USA
| | - Maxim Topaz
- Columbia University School of Nursing, New York, NY, USA
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2
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Xu J, Xu W, Qiu Y, Gong D, Man C, Fan Y. Association of Prefrailty and Frailty With All-Cause Mortality, Acute Exacerbation, and Hospitalization in Patients With Chronic Obstructive Pulmonary Disease: A Meta-Analysis. J Am Med Dir Assoc 2023; 24:937-944.e3. [PMID: 37150209 DOI: 10.1016/j.jamda.2023.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE To evaluate the impact of prefrailty and frailty on all-cause mortality, acute exacerbation, and all-cause hospitalization in patients with chronic obstructive pulmonary disease (COPD). DESIGN Meta-analysis. SETTING AND PARTICIPANTS Two authors independently searched PubMed, Web of Science, and Embase databases until December 27, 2022,to identify studies that reported the predictive value of prefrailty and frailty in COPD patients. MEASUREMENTS All-cause mortality, acute exacerbation, and all-cause hospitalization. RESULTS Ten studies reporting on 11 articles enrolling 13,203 patients with COPD were included. The prevalence of frailty ranged from 6.0% to 51%. When compared with nonfrailty, the pooled adjusted hazard ratio (HR) of all-cause mortality was 1.48 (95% CI 0.92-2.40) for prefrailty and 2.64 (95% CI 1.74-4.02) for frailty, respectively. The pooled adjusted odds ratio (OR) of all-cause hospitalization was 1.35 (95% CI 1.05-1.74) for prefrailty and 1.65 (95% CI 1.05-2.61) for frailty. In addition, frailty significantly predicted all acute exacerbation (OR 2.20, 95% CI 1.26-3.81) but not moderate to severe acute exacerbation (OR 1.42, 95% CI 0.94-2.17) in patients with stable COPD. However, the pooled results of all-cause hospitalization were not reliable in leave-1-out sensitivity analyses. CONCLUSIONS AND IMPLICATIONS Frailty significantly predicts all-cause mortality in patients with COPD, even after adjustment for common confounding factors. Assessment of frail status in COPD patients may improve secondary prevention and allow early intervention. However, future studies are warranted to validate the impact of frailty defined by a standardized definition of frailty on acute exacerbation and all-cause hospitalization.
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Affiliation(s)
- Juan Xu
- Department of Oncology, Ganyu District People's Hospital of Lianyungang City, Lianyungang, Jiangsu, China
| | - Wei Xu
- Cancer Institute, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, Jiangsu, China
| | - Yue Qiu
- Cancer Institute, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, Jiangsu, China
| | - Dandan Gong
- Cancer Institute, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, Jiangsu, China
| | - Changfeng Man
- Cancer Institute, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, Jiangsu, China
| | - Yu Fan
- Cancer Institute, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, Jiangsu, China.
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McCarthy EP, Lopez RP, Hendricksen M, Mazor KM, Roach A, Rogers AH, Epps F, Johnson KS, Akunor H, Mitchell SL. Black and white proxy experiences and perceptions that influence advanced dementia care in nursing homes: The ADVANCE study. J Am Geriatr Soc 2023; 71:1759-1772. [PMID: 36856071 PMCID: PMC10258152 DOI: 10.1111/jgs.18303] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/02/2023] [Accepted: 01/08/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Regional, facility, and racial variability in intensity of care provided to nursing home (NH) residents with advanced dementia is poorly understood. MATERIALS AND METHODS Assessment of Disparities and Variation for Alzheimer's disease NH Care at End of life (ADVANCE) is a multisite qualitative study of 14 NHs from four hospital referral regions providing varied intensity of advanced dementia care based on tube-feeding and hospital transfer rates. This report explored the perceptions and experiences of Black and White proxies (N = 44) of residents with advanced dementia to elucidate factors driving these variations. Framework analyses revealed themes and subthemes within the following a priori domains: understanding of advanced dementia and care decisions, preferences related to end-of-life care, advance care planning, decision-making about managing feeding problems and acute illness, communication and trust in NH providers, support, and spirituality in decision-making. Matrix analyses explored similarities/differences by proxy race. Data were collected from June 1, 2018 to July 31, 2021. RESULTS Among 44 proxies interviewed, 19 (43.1%) were Black, 36 (81.8%) were female, and 26 (59.0%) were adult children of residents. In facilities with the lowest intensity of care, Black and White proxies consistently reported having had previous conversations with residents about wishes for end-of-life care and generally better communication with providers. Black proxies held numerous misconceptions about the clinical course of advanced dementia and effectiveness of treatment options, notably tube-feeding and cardiopulmonary resuscitation. Black and White proxies described mistrust of NH staff but did so towards different staffing roles. Religious and spiritual beliefs commonly thought to underlie preferences for more intense care among Black residents, were rarely, but equally mentioned by race. CONCLUSIONS This report refuted commonly held assumptions about religiosity and spirituality as drivers of racial variations in advanced dementia care and revealed several actionable facility-level factors, which may help reduce these variations.
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Affiliation(s)
- Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ruth Palan Lopez
- School of Nursing, MGH Institute of Health Professions, Boston, Massachusetts, USA
| | - Meghan Hendricksen
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, Massachusetts, USA
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ashley Roach
- School of Nursing, Oregon Health & Science University, Portland, Oregon, USA
| | - Anita Hendrix Rogers
- Department of Nursing, The University of Tennessee at Martin, Martin, Tennessee, USA
| | - Fayron Epps
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Kimberly S Johnson
- Division of Geriatrics, Department of Medicine, Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina, USA
- Geriatrics Research Education and Clinical Center, Veteran Affairs Medicine Center, Durham, North Carolina, USA
| | - Harriet Akunor
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Tesini BL, Dumyati G. Health Care-Associated Infections in Older Adults: Epidemiology and Prevention. Infect Dis Clin North Am 2023; 37:65-86. [PMID: 36805015 DOI: 10.1016/j.idc.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Health care-associated infections (HAIs) are a global public health threat, which disproportionately impact older adults. Host factors including aging-related changes, comorbidities, and geriatric syndromes, such as dementia and frailty, predispose older individuals to infection. The HAI risks from medical interventions such as device use, antibiotic use, and lapses in infection control follow older adults as they transfer among a network of interrelated acute and long-term care facilities. Long-term care facilities are caring for patients with increasingly complex needs, and the home-like communal environment of long-term care facilities creates distinct infection prevention challenges.
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Affiliation(s)
- Brenda L Tesini
- Division of Infectious Diseases, Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, USA.
| | - Ghinwa Dumyati
- Division of Infectious Diseases, Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, USA
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Tyler N, Planner C, Shears B, Hernan A, Panagioti M, Giles S. Developing the Resident Measure of Safety in Care Homes (RMOS): A Delphi and Think Aloud Study. Health Expect 2023; 26:1149-1158. [PMID: 36797827 PMCID: PMC10154851 DOI: 10.1111/hex.13730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/26/2023] [Accepted: 02/05/2023] [Indexed: 02/18/2023] Open
Abstract
OBJECTIVE This study aimed to develop a measure of contributory factors to safety incidents in care homes to be completed by residents and/or their unpaid carers. INTRODUCTION Care home residents are particularly vulnerable to patient safety incidents, due to higher likelihood of frailty, multimorbidity and cognitive decline. However, despite residents and their carers wanting to be involved in safety initiatives, there are few mechanisms for them to contribute and make meaningful safety improvements to practice. METHODS We developed 73 evidence-based items from synthesis and existing measures, which we presented to a panel of stakeholders (residents/carers, health/social care professionals and researchers). We used two online rounds of Delphi to generate consensus (80%) on items important to include in the Resident Measure of Safety in Care Homes (RMOS); a consensus meeting was later held. The draft RMOS developed through the Delphi was presented to participants during 'Think Aloud' interviews using cognitive testing techniques. RESULTS The 29-item RMOS was developed. Forty-three participants completed Delphi round 1, and 27 participants completed round 2, 11 participants attended the consensus meeting and 12 'Think Aloud' interviews were conducted. Of the 73 original items, 42 items that did not meet consensus in Delphi round 1 were presented in round 2. After the consensus meeting, it was agreed that 35 items would comprise the RMOS questionnaire and were presented in the 'Think Aloud' interviews. Participants suggested numerous changes to items mostly to improve comprehension and ability to answer. CONCLUSION We have a developed an evidence-based RMOS, with good face validity, to assess contributory factors to safety in care homes from a resident/carer perspective. Future work will involve psychometrically testing the items in a pilot and developing a complementary simplified, dementia-friendly version to promote inclusivity. PATIENT OR PUBLIC INVOLVEMENT Four patient and public contributors worked with researchers to develop the online questionnaires. Patients (residents) and carers participated on the consensus panel. One member of the research team is an expert by lived experience and was involved in design and analysis decisions. The item list and instructions for the questionnaires were reviewed for face validity, understanding and acceptability by a patient and public involvement group and modified.
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Affiliation(s)
- Natasha Tyler
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,National Institute for Health and Care Research School for Primary Care Research, University of Manchester, Manchester, UK
| | - Claire Planner
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Bethany Shears
- Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Andrea Hernan
- Faculty of Health, Deakin University, Warrnambool, Australia
| | - Maria Panagioti
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,National Institute for Health and Care Research School for Primary Care Research, University of Manchester, Manchester, UK
| | - Sally Giles
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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Valk-Draad MP, Bohnet-Joschko S. [Nursing home-sensitive conditions and approaches to reduce hospitalization of nursing home residents]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:199-211. [PMID: 36625862 PMCID: PMC9830609 DOI: 10.1007/s00103-022-03654-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Interventions to reduce potentially risky hospitalizations among nursing home residents are highly relevant for patient safety and quality improvement. A catalog of nursing home-sensitive conditions (NHSCs) grounds the policy recommendations and interventions. METHODS In two previous research phases, an expert panel developed a catalog of 58 NHSCs using an adapted Delphi-procedure (the RAND/UCLA Appropriateness Method). This procedure was developed by the North American non-profit Research and Development Organisation (RAND) and clinicians of the University of California in Los Angeles (UCLA). We present the third phase of the project focused on the development of interventions to reduce NHSCs starting with an expert workshop. The workshop results were then evaluated by six experts from related sectors, supplemented, and systematically used to produce recommendations for action. Possible implementation obstacles were considered and the time horizon of effectiveness was estimated. RESULTS The recommendations address communication, cooperation, documentation and care competence as well as facility-related, financial, and legal aspects. Indication bundles demonstrate the relevance for the German healthcare system. To increase effectiveness, the experts advise a meaningful combination of individual recommendations. DISCUSSION By optimizing multidisciplinary communication and cooperation, combined with an- also digital - expansion of the infrastructure and the creation of institution-specific and legal prerequisites as well as remuneration structures, an estimated 35% of all hospitalizations, approximately 220,000 hospitalizations for Germany, could be prevented. The implementation expenditure could be refinanced by avoided hospitalization savings amounting to 768 million euros.
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Affiliation(s)
- Maria Paula Valk-Draad
- Lehrstuhl für Management und Innovation im Gesundheitswesen, Fakultät für Wirtschaft und Gesellschaft, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Deutschland
- Lehrstuhl für Community Health Nursing, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Deutschland
| | - Sabine Bohnet-Joschko
- Lehrstuhl für Management und Innovation im Gesundheitswesen, Fakultät für Wirtschaft und Gesellschaft, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Deutschland.
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Katz PR, Smalbrugge M, Karuza J, Costa A, Nazir A, Wasserman MR, Nelson D, Levenson SA, Resnick B. Raising the Bar for Physicians Practicing in Nursing Homes: The Path to Sustainable Improvement. J Am Med Dir Assoc 2023; 24:131-133. [PMID: 36725202 DOI: 10.1016/j.jamda.2022.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Paul R Katz
- Department of Geriatrics, FSU College of Medicine, Tallahassee, FL, USA.
| | - Martin Smalbrugge
- Department of Medicine for Older People Vrije University and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Jurgis Karuza
- Division of Geriatrics, University of Rochester, Rochester, NY, USA
| | - Andrew Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Arif Nazir
- Chief Medical Officer, Primary Care at BrightSpring Health Services, Louisville, KY, USA
| | | | - Dallas Nelson
- Division of Geriatrics, University of Rochester, Rochester, NY, USA
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O'Neill BJ, Dwyer T, Parkinson L, Reid-Searl K, Jeffrey D. Identifying the core components of a nursing home hospital avoidance programme. Int J Older People Nurs 2023; 18:e12493. [PMID: 35943901 PMCID: PMC10078518 DOI: 10.1111/opn.12493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 05/23/2022] [Accepted: 06/27/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Nursing home hospital avoidance programmes have contributed to a reduction in unnecessary emergency transfers but a description of the core components of the programmes has not been forthcoming. A well-operationalised health-care programme requires clarity around core components to evaluate and replicate the programme. Core components are the essential functions and principles that must be implemented to produce expected outcomes. OBJECTIVES To identify the core components of a nursing home hospital avoidance programme by assessing how the core components identified at one nursing home (Site One) translated to a second nursing home (Site Two). METHODS Data collected during the programme's implementation at Site Two were reviewed for evidence of how the core components named at Site One were implemented at Site Two and to determine if any additional core components were evident. The preliminary updated core components were then shared with seven evaluators familiar with the hospital avoidance programme for consensus. RESULTS The updated core components were agreed to include the following: Decision Support Tools, Advanced Clinical Skills Training, Specialist Clinical Support and Collaboration, Facility Policy and Procedures, Family and Care Recipient Education and Engagement, Culture of Staff Readiness, Supportive Executive and Facility Management. CONCLUSION This study launches a discussion on the need to identify hospital avoidance programme core components, while providing valuable insight into how Site One core programme components, such as resources, education and training, clinical and facility support, translated to Site Two, and why modifications and additions, such as incorporating the programme into facility policy, family education and executive support were necessary, and the ramifications of those changes. The next step is to take the eight core component categories and undertake a rigorous fidelity assessment as part of formal process evaluation where the components can be critiqued and measured across multiple nursing home sites. The core components can then be used as evidence-based building blocks for developing, implementing and evaluating nursing home hospital avoidance programmes.
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Affiliation(s)
- Barbara J O'Neill
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Rockhampton, Queensland, Australia.,School of Nursing, University of Connecticut, Storrs, Connecticut, USA
| | - Trudy Dwyer
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Rockhampton, Queensland, Australia
| | - Lynne Parkinson
- School of Medicine and Public Health, University of New Castle, Callaghan, New South Wales, Australia
| | - Kerry Reid-Searl
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Rockhampton, Queensland, Australia
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TYLER DENISEA, FENG ZHANLIAN, GRABOWSKI DAVIDC, BERCAW LAWREN, SEGELMAN MICAH, KHATUTSKY GALINA, WANG JOYCE, GASDASKA ANGELA, INGBER MELVINJ. CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned. Milbank Q 2022; 100:1243-1278. [PMID: 36573335 PMCID: PMC9836234 DOI: 10.1111/1468-0009.12594] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/20/2022] [Accepted: 07/27/2022] [Indexed: 12/28/2022] Open
Abstract
Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone. CONTEXT In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only). METHODS Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality. FINDINGS Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations. CONCLUSIONS Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.
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10
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Anderson TS, Marcantonio ER, McCarthy EP, Ngo L, Schonberg MA, Herzig SJ. Association of Diagnosed Dementia with Post-discharge Mortality and Readmission Among Hospitalized Medicare Beneficiaries. J Gen Intern Med 2022; 37:4062-4070. [PMID: 35415794 PMCID: PMC9708999 DOI: 10.1007/s11606-022-07549-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/30/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with dementia are frequently hospitalized and may face barriers in post-discharge care. OBJECTIVE To determine whether patients with dementia have an increased risk of adverse outcomes following discharge. DESIGN Retrospective cohort study. SUBJECTS Medicare beneficiaries hospitalized in 2016. MAIN MEASURES Co-primary outcomes were mortality and readmission within 30 days of discharge. Multivariable logistic regression models were estimated to assess the risk of each outcome for patients with and without dementia accounting for demographics, comorbidities, frailty, hospitalization factors, and disposition. KEY RESULTS The cohort included 1,089,109 hospitalizations of which 211,698 (19.3%) were of patients with diagnosed dementia (median (IQR) age 83 (76-89); 61.5% female) and 886,411 were of patients without dementia (median (IQR) age 76 (79-83); 55.0% female). At 30 days following discharge, 5.7% of patients with dementia had died compared to 3.1% of patients without dementia (adjusted odds ratio (aOR) 1.21; 95% CI 1.17 to 1.24). At 30 days following discharge, 17.7% of patients with dementia had been readmitted compared to 13.1% of patients without dementia (aOR 1.02; CI 1.002 to 1.04). Dementia was associated with an increased odds of readmission among patients discharged to the community (aOR 1.07, CI 1.05 to 1.09) but a decreased odds of readmission among patients discharge to nursing facilities (aOR 0.93, CI 0.90 to 0.95). Patients with dementia who were discharged to the community were more likely to be readmitted than those discharged to nursing facilities (18.9% vs 16.0%), and, when readmitted, were more likely to die during the readmission (20.7% vs 4.4%). CONCLUSIONS Diagnosed dementia was associated with a substantially increased risk of mortality and a modestly increased risk of readmission within 30 days of discharge. Patients with dementia discharged to the community had particularly elevated risk of adverse outcomes indicating possible gaps in post-discharge services and caregiver support.
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Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02446, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02446, USA
- Harvard Medical School, Boston, MA, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ellen P McCarthy
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02446, USA
- Harvard Medical School, Boston, MA, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Long Ngo
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02446, USA
- Harvard Medical School, Boston, MA, USA
| | - Mara A Schonberg
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02446, USA
- Harvard Medical School, Boston, MA, USA
| | - Shoshana J Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02446, USA
- Harvard Medical School, Boston, MA, USA
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11
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Registered Nurses’ Experiences of End-of-Life Care in Nursing Homes of South Korea: A Qualitative Study. Healthcare (Basel) 2022; 10:healthcare10112213. [PMID: 36360554 PMCID: PMC9690043 DOI: 10.3390/healthcare10112213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022] Open
Abstract
This study aimed to qualitatively describe how registered nurses (RNs) experienced and perceived end-of-life (EOL) care for older residents in South Korean nursing homes. The participants included 11 nurses with experience of providing EOL care for older residents in six nursing homes. Data were collected through one-on-one in-depth interviews using semi-structured questions from 27 December 2019 to 22 October 2020. Around 1–2 interviews were conducted for each participant, and each interview lasted between 40 min and two hours. The interview data were analyzed using qualitative content analysis. Eight sub-themes were identified and abstracted under three themes: (a) “feeling fulfilled for doing my best until the last day,” (b) “defensive coping due to legal and institutional limitations,” and (c) “requirements for effective EOL care.” This study suggests that there are many challenges and issues regarding EOL care at nursing homes. In order to provide effective EOL care to older residents, the foundation of the EOL care system, as well as skills training, should be strengthened. Furthermore, securing qualified nursing manpower and achieving institutional improvement by reducing obstacles are warranted.
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12
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Tyler DA, Kordomenos C, Ingber MJ. Reducing Hospitalizations Among Nursing Facility Residents: Policy Environment and Suggestions for the Future in Seven States. J Gerontol Nurs 2022; 48:10-16. [PMID: 35914083 DOI: 10.3928/00989134-20220629-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The current study examined the policy and market context existing in the seven states where the Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents took place. Stakeholder organizations with knowledge of the skilled nursing facility environment but who were not directly involved with the CMS Initiative were interviewed to assess the impact of policies and programs affecting transfers to the hospital from long-term care facilities. Focused interviews were used to identify areas of quality improvement as well as market forces that contributed to hospitalization rates. Interviews were qualitatively coded and emerging patterns and themes were identified. Market pressures were similar across states. Few policies were found that may have affected the Initiative, but most states had regional coalitions focused on improving some aspect of care. When asked what else could be done to reduce hospitalizations among nursing facility residents, participants across the stakeholder organizations suggested greater presence of physicians and nurse practitioners in nursing facilities, better training around behavioral health issues for frontline staff, and more advance care planning and education for families regarding end of life. [Journal of Gerontological Nursing, 48(8), 10-16.].
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Ersek M, Sales A, Keddem S, Ayele R, Haverhals LM, Magid KH, Kononowech J, Murray A, Carpenter JG, Foglia MB, Potter L, McKenzie J, Davis D, Levy C. Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration. Implement Sci Commun 2022; 3:78. [PMID: 35859140 PMCID: PMC9296899 DOI: 10.1186/s43058-022-00321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings. METHODS PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations. DISCUSSION The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.
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Affiliation(s)
- Mary Ersek
- Center for Health Equity and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Annex Suite 203, Philadelphia, PA, 19104, USA. .,University of Pennsylvania Schools of Nursing and Medicine, Philadelphia, PA, USA.
| | - Anne Sales
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Shimrit Keddem
- Center for Health Equity and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Annex Suite 203, Philadelphia, PA, 19104, USA.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Roman Ayele
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Leah M Haverhals
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kate H Magid
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Andrew Murray
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Joan G Carpenter
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,University of Maryland School of Nursing, Baltimore, MD, USA
| | - Mary Beth Foglia
- VA National Center for Ethics in Health Care, Washington, D.C., USA.,Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
| | - Lucinda Potter
- VA National Center for Ethics in Health Care, Washington, D.C., USA
| | - Jennifer McKenzie
- VA Purchased Long-Term Services and Supports, Geriatrics and Extended Care, D, Washington, .C, USA
| | - Darlene Davis
- Home-Based Primary Care Program, Office of Geriatrics and Extended Care, Washington, D.C., USA
| | - Cari Levy
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Lage DE, Keating NL, Temel JS. Integrating Functional Assessment Into Clinical Decision-Making for Older Adults Across the Cancer Care Continuum. JCO Oncol Pract 2022; 18:e1056-e1059. [PMID: 35549305 PMCID: PMC9287289 DOI: 10.1200/op.22.00231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/15/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Daniel E. Lage
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Nancy L. Keating
- Department of Medicine, Harvard Medical School, Boston, MA
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Department of Medicine, Brigham & Women's Hospital, Boston, MA
| | - Jennifer S. Temel
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
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15
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de Araújo JRT, Jerez-Roig J, Machado DGDS, Ferreira LMDBM, de Lima KC. Mobility during walking and incidence and risk factors for mobility decline among institutionalized older adults: A two-year longitudinal study. Arch Gerontol Geriatr 2022; 101:104702. [DOI: 10.1016/j.archger.2022.104702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/02/2022] [Accepted: 04/04/2022] [Indexed: 11/29/2022]
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16
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Akunor HS, McCarthy EP, Hendricksen M, Roach A, Hendrix Rogers A, Mitchell SL, Lopez RP. Nursing Home Staff Perceptions of End-of-Life Care for Residents With Advanced Dementia: A Multisite Qualitative Study. J Hosp Palliat Nurs 2022; 24:152-158. [PMID: 35195109 PMCID: PMC9058147 DOI: 10.1097/njh.0000000000000843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nursing homes (NHs) are an important site of death for residents with advanced dementia. Few studies have explored the experiences of NH staff about providing end-of-life care for residents with advanced dementia. This study aimed to describe NH staff perceptions on where end-of-life care should be delivered, the role of Medicare hospice care, and their experiences providing end-of-life care to residents with advanced dementia. Data from the Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life study were used to explore the study objectives. Semistructured interviews with 158 NH staff working in 13 NHs across the United States were analyzed. Most NH staff endorsed the NH as a better site of death for residents with advanced dementia compared with a hospital. They expressed mixed perceptions about hospice care. However, regardless of their role, the staff expressed experiencing difficult emotions while providing end-of-life care to residents with dementia because of the close attachments they had formed with them and bearing witness to their decline. The findings show that most NH staff have strong emotional attachments to their dying residents with dementia and prefer to care for them at the NH rather than transfer them to the hospital.
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Giacomini G, Minutiello E, Politano G, Dalmasso M, Albanesi B, Campagna S, Gianino MM. Trajectories and determinants of emergency department use among nursing home residents: a time series analysis (2012-2019). BMC Geriatr 2022; 22:418. [PMID: 35549898 PMCID: PMC9101855 DOI: 10.1186/s12877-022-03078-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Emergency department (ED) use among nursing home (NH) residents is an internationally-shared issue that is understudied in Italy. The long term care in Italy is part of the health system. This study aimed to assess trajectories of ED use among NH residents and determinants between demographic, health supply, clinical/functional factors. Methods A pooled, cross-sectional, time series analysis was performed in an Italian region in 2012/2019. The analysis measured the trend of ED user percentages associated with chronic conditions identified at NH admission. A GLM multivariate model was used to evaluate determinants of ED use. The variables collected were sex, age, assistance intensity, destination after discharge from NH, chronic conditions at NH admission, need for daily life assistance, degree of mobility, cognitive impairments, behavioural disturbances and were taken from two databases of the official Italian National Information System (FAR and C2 registries) that were combined to create a unique and anonymous code for each patient. Results A total of 37,311 residents were enrolled; 55.75% (20,800 residents) had at least one ED visit. The majority of the residents had cardiovascular (25.99%) or mental diseases (24.37%). In all pathologies, the percentage of ED users decreased and the decrease accelerated over time. These results were confirmed in the fixed effects regression model (coefficient for linear term (b = − 3.6177, p = 0, 95% CI = [− 5.124, − 2.1114]); coefficient for quadratic term = − 0.7691, p = 0.0046, 95% CI = [− 1.2953, − 0.2429]). Analysis showed an increased odds of ED visits involving males (OR = 1.27, 95% CI 1.24;1.30) and patients affected by urogenital diseases (OR = 1.16, 95% CI [1.031–1.314]). The lowest odds of ED visits were observed among subjects aged > 90 years (OR = 0.64, 95% CI [0.60–0.67]), who required assistance for their daily life activities (OR = 0.86; 95% CI = [0.82, 0.91]), or with serious cognitive disturbances (OR = 0.86; 95% CI = [0.84, 0.89]), immobile (OR = 0.93; 95% CI = [0.89, 0.96]), or without behavioural disturbances (OR = 0.92; 95% CI = [0.90, 0.94]). Conclusions The percentage of ED users has decreased, through support from the Italian disciplinary long-term care system. The demographic, clinical/functional variables associated with ED visits in this study will be helpful to develop targeted and tailored interventions to avoid unnecessary ED use.
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Affiliation(s)
- Gianmarco Giacomini
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Ettore Minutiello
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Gianfranco Politano
- Department of Control and Computer Engineering, Politecnico di Torino, Torino, Italy
| | - Marco Dalmasso
- Unit of Epidemiology- Local Health Unit TO3, Via Sabaudia 164, Turin, Grugliasco, Italy
| | - Beatrice Albanesi
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Sara Campagna
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Maria Michela Gianino
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy.
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Carnahan JL, Unroe KT, Evans R, Klepfer S, Stump TE, Monahan PO, Torke AM. The Avoidable Transfer Scale: A New Tool for Identifying Potentially Avoidable Hospital Transfers of Nursing Home Residents. Innov Aging 2022; 6:igac031. [PMID: 35832205 PMCID: PMC9273404 DOI: 10.1093/geroni/igac031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Indexed: 12/05/2022] Open
Abstract
Background and Objectives Prior approaches to identifying potentially avoidable hospital transfers (PAHs) of nursing home residents have involved detailed root cause analyses that are difficult to implement and sustain due to time and resource constraints. They relied on the presence of certain conditions but did not identify the specific issues that contributed to avoidability. We developed and tested an instrument that can be implemented using review of the electronic medical record. Research Design and Methods The OPTIMISTIC project was a Centers for Medicare and Medicaid Services demonstration to reduce avoidable hospital transfers of nursing home residents. The OPTIMISTIC team conducted a series of root cause analyses of transfer events, leading to development of a 27-item instrument to identify common characteristics of PAHs (Stage 1). To refine the instrument, project nurses used the electronic medical record (EMR) to score the avoidability of transfers to the hospital for 154 nursing home residents from 7 nursing homes from May 2019 through January 2020, including their overall impression of whether the transfer was avoidable (Stage 2). Each transfer was rated independently by 2 nurses and assessed for interrater reliability with a kappa statistic. Results Kappa scores ranged from −0.045 to 0.556. After removing items based on our criteria, 12 final items constituted the Avoidable Transfer Scale. To assess validity, we compared the 12-item scale to nurses’ overall judgment of avoidability of the transfer. The 12-item scale scores were significantly higher for submissions rated as avoidable than those rated unavoidable by the nurses (mean 5.3 vs 2.6, p < .001). Discussion and Implications The 12-item Avoidable Transfer Scale provides an efficient approach to identify and characterize PAHs using available data from the EMR. Increased ability to quantitatively assess the avoidability of resident transfers can aid nursing homes in quality improvement initiatives to treat more acute changes in a resident’s condition in place.
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Affiliation(s)
- Jennifer L Carnahan
- Indiana University School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., IU Center for Aging Research, Indianapolis, Indiana, USA
| | - Kathleen T Unroe
- Indiana University School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., IU Center for Aging Research, Indianapolis, Indiana, USA
| | | | | | - Timothy E Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Patrick O Monahan
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alexia M Torke
- Indiana University School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., IU Center for Aging Research, Indianapolis, Indiana, USA
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Vogelsmeier A, Popejoy L, Fritz E, Canada K, Ge B, Brandt L, Rantz M. Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity. BMC Health Serv Res 2022; 22:626. [PMID: 35538575 PMCID: PMC9087933 DOI: 10.1186/s12913-022-08036-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers. Methods This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described. Results Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable. Conclusions Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.
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Affiliation(s)
- Amy Vogelsmeier
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.
| | - Lori Popejoy
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Elizabeth Fritz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Kelli Canada
- School of Social Work, University of Missouri, Columbia, MO, USA
| | - Bin Ge
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Lea Brandt
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Marilyn Rantz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
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20
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Nursing Leadership and Palliative Care in Long-Term Care for Residents with Advanced Dementia. Nurs Clin North Am 2022; 57:259-271. [DOI: 10.1016/j.cnur.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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21
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Dowling MJ, Molloy U, Payne C, McLean S, McQuillan R, Noonan C, Ryan DJ. Hospital transfer rates and advance care planning following a nursing home-targeted video-conference education series (Project ECHO): a prospective cohort study. Eur Geriatr Med 2022; 13:941-949. [PMID: 35438449 PMCID: PMC9016377 DOI: 10.1007/s41999-022-00624-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 02/08/2022] [Indexed: 11/17/2022]
Abstract
Purpose Nursing home staff manage increasingly complex patients yet struggle to access education. This study measured the impact of a novel education programme on emergency transfers from nursing homes. Methods In this prospective experimental cohort study, ten interactive sessions were provided to 20 nursing homes, using teleconferencing technology through the “Project ECHO” (Extension for Community Healthcare Outcomes) model. Details of all emergency hospital transfers were submitted by participating nursing homes 6 months before and 6 months from commencement of ECHO. Results Of 20 nursing homes, 13 submitted sufficient data for inclusion. In these 13, there were 260 emergency transfers over a year. There was no significant difference in the number of transfers before and after ECHO (137/260 pre-ECHO vs 123/260 post-ECHO, p = 0.62). Post-ECHO, it was 50% more likely that transfer wishes were discussed in advance of transfer (62 of 137 (45%) transferred pre-ECHO vs 82 of 123 (67%) post-ECHO, p < 0.001). There was a significant increase in compliance with resident wishes post-ECHO in that transferred residents were less likely to have a documented “Not for Transfer” wish (29/137 pre-ECHO (21%) vs 10/123 post-ECHO (8%), p < 0.001). Point prevalence surveys of residents demonstrated significant increases in “Do Not Resuscitate” orders; 286/589 (49%) residents pre-ECHO vs 386/594 (65%) post-ECHO, p < 0.001. Post-ECHO, pain was less frequently the primary cause for transfer (11/137 (8%) pre-ECHO vs 1/123 (0.8%) post-ECHO, p = 0.006). Conclusion ECHO did not affect rates of emergency hospital transfers but did increase advance care planning discussions ahead of hospital transfer by 50% and compliance with the results of those discussions. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-022-00624-6. Aim What effect does a novel education programme have on emergency hospital transfers of, and advance care planning decisions among, nursing home residents? Findings This education programme did not affect overall rates of emergency hospital transfer. It did increase advance care planning discussions, increase compliance with the results of these discussions and increase “DNR” orders among nursing home residents. Message Novel tele-education programmes have the potential to improve advance care planning discussions in nursing homes. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-022-00624-6.
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Affiliation(s)
- Michael J Dowling
- Age-Related Healthcare Department, Tallaght University Hospital, Dublin 24, Ireland.
| | | | - Cathy Payne
- All-Ireland Institute of Hospice and Palliative Care, Dublin, Ireland
| | | | | | - Claire Noonan
- Age-Related Healthcare Department, Tallaght University Hospital, Dublin 24, Ireland
| | - Dan J Ryan
- Age-Related Healthcare Department, Tallaght University Hospital, Dublin 24, Ireland.,Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
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22
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McCreedy EM, Yang X, Mitchell SL, Gutman R, Teno J, Loomer L, Moyo P, Volandes A, Gozalo PL, Belanger E, Ogarek J, Mor V. Effect of advance care planning video on do-not-hospitalize orders for nursing home residents with advanced illness. BMC Geriatr 2022; 22:298. [PMID: 35392827 PMCID: PMC8991654 DOI: 10.1186/s12877-022-02970-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of the study is to evaluate the effect of an Advance Care Planning (ACP) Video Program on documented Do-Not-Hospitalize (DNH) orders among nursing home (NH) residents with advanced illness. METHODS Secondary analysis on a subset of NHs enrolled in a cluster-randomized controlled trial (41 NHs in treatment arm implemented the ACP Video Program: 69 NHs in control arm employed usual ACP practices). Participants included long (> 100 days) and short (≤ 100 days) stay residents with advanced illness (advanced dementia or cardiopulmonary disease (chronic obstructive pulmonary disease or congestive heart failure)) in NHs from March 1, 2016 to May 31, 2018 without a documented Do-Not-Hospitalize (DNH) order at baseline. Logistic regression with covariate adjustments was used to estimate the impact of the resident being in a treatment versus control NH on: the proportion of residents with new DNH orders during follow-up; and the proportion of residents with any hospitalization during follow-up. Clustering at the facility-level was addressed using hierarchical models. RESULTS The cohort included 6,117 residents with advanced illness (mean age (SD) = 82.8 (8.4) years, 65% female). Among long-stay residents (n = 3,902), 9.3% (SE, 2.2; 95% CI 5.0-13.6) and 4.2% (SE, 1.1; 95% CI 2.1-6.3) acquired a new DNH order in the treatment and control arms, respectively (average marginal effect, (AME) 5.0; SE, 2.4; 95% CI, 0.3-9.8). Among short-stay residents with advanced illness (n = 2,215), 8.0% (SE, 1.6; 95% CI 4.6-11.3) and 3.5% (SE 1.0; 95% CI 1.5-5.5) acquired a new DNH order in the treatment and control arms, respectively (AME 4.4; SE, 2.0; 95% CI, 0.5-8.3). Proportion of residents with any hospitalizations did not differ between arms in either cohort. CONCLUSIONS Compared to usual care, an ACP Video Program intervention increased documented DNH orders among NH residents with advanced disease but did not significantly reduce hospitalizations. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02612688 .
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Affiliation(s)
- Ellen M McCreedy
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA. .,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.
| | - Xiaofei Yang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St, Boston, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Joan Teno
- Oregon Health Sciences University School of Medicine, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business and Economics, University of Minnesota Duluth, 1518 Kirby Dr, Duluth, MN, 55806, USA
| | - Patience Moyo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Angelo Volandes
- Section of General Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Emmanuelle Belanger
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Jessica Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main St, Providence, RI, 02912, USA
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23
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Moyo P, Loomer L, Teno J, Gutman R, McCreedy EM, Bélanger E, Volandes AE, Mitchell S, Mor V. Effect of a Video-Assisted Advance Care Planning Intervention on End-of-Life Health Care Transitions Among Long-Stay Nursing Home Residents. J Am Med Dir Assoc 2022; 23:394-398. [PMID: 34627753 PMCID: PMC8885779 DOI: 10.1016/j.jamda.2021.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the relationship between an advance care planning (ACP) video intervention, Pragmatic Trial of Video Education in Nursing Homes (PROVEN), and end-of-life health care transitions among long-stay nursing home residents with advanced illness. DESIGN Pragmatic cluster randomized clinical trial. Five ACP videos were available on tablets or online at intervention facilities. PROVEN champions employed by nursing homes (usually social workers) were directed to offer residents (or their proxies) ≥1 video under certain circumstances. Control facilities employed usual ACP practices. SETTING AND PARTICIPANTS PROVEN occurred from February 2016 to May 2019 in 360 nursing homes (119 intervention, 241 control) owned by 2 health care systems. This post hoc study of PROVEN data analyzed long-stay residents ≥65 years who died during the trial who had either advanced dementia or cardiopulmonary disease (advanced illness). We required an observation time ≥90 days before death. The analytic sample included 923 and 1925 advanced illness decedents in intervention and control arms; respectively. METHODS Outcomes included the proportion of residents with 1 or more hospital transfer (ie, hospitalization, emergency department use, or observation stay), multiple (≥3) hospital transfers during the last 90 days of life, and late transitions (ie, hospital transfer during the last 3 days or hospice admission on the last day of life). RESULTS Hospital transfers in the last 90 days of life among decedents with advanced illness were significantly lower in the intervention vs control arm (proportion difference = -1.7%, 95% CI -3.2%, -0.1%). The proportion of decedents with multiple hospital transfers and late transitions did not differ between the trial arms. CONCLUSIONS AND IMPLICATIONS Video-assisted ACP was modestly associated with reduced hospital transfers in the last 90 days of life among nursing home residents with advanced illness. The intervention was not significantly associated with late health care transitions and multiple hospital transfers.
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Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Lacey Loomer
- University of Minnesota Duluth Labovitz School of Business
and Economics, Department of Economics and Health Care Management, Duluth, MN,
USA
| | - Joan Teno
- Oregon Health Sciences University School of Medicine,
Portland, OR, USA
| | - Roee Gutman
- Brown University School of Public Health, Department of
Biostatistics, Providence, RI, USA
| | - Ellen M. McCreedy
- Brown University School of Public Health, Department of
Health Services, Policy, and Practice, Providence, RI, USA
| | - Emmanuelle Bélanger
- Brown University School of Public Health, Department of
Health Services, Policy, and Practice, Providence, RI, USA
| | - Angelo E. Volandes
- General Medicine, Harvard Medical School, Boston, MA,
USA,Section of General Medicine, Massachusetts General
Hospital, Boston, MA
| | - Susan Mitchell
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for
Aging Research, Boston, MA, USA,Department of Medicine, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - Vincent Mor
- Brown University School of Public Health, Department of
Health Services, Policy, and Practice, Providence, RI, USA,Providence VA Medical Center, Long Term Services and
Supports Center of Innovation, Providence, RI, USA
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Tu W, Li R, Stump TE, Fowler NR, Carnahan JL, Blackburn J, Sachs GA, Hickman SE, Unroe KT. Age-specific rates of hospital transfers in long-stay nursing home residents. Age Ageing 2022; 51:6430100. [PMID: 34850811 DOI: 10.1093/ageing/afab232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION hospital transfers and admissions are critical events in the care of nursing home residents. We sought to determine hospital transfer rates at different ages. METHODS a cohort of 1,187 long-stay nursing home residents who had participated in a Centers for Medicare and Medicaid demonstration project. We analysed the number of hospital transfers of the study participants recorded by the Minimum Data Set. Using a modern regression technique, we depicted the annual rate of hospital transfers as a smooth function of age. RESULTS transfer rates declined with age in a nonlinear fashion. Rates were the highest among residents younger than 60 years of age (1.30-2.15 transfers per year), relatively stable between 60 and 80 (1.17-1.30 transfers per year) and lower in those older than 80 (0.77-1.17 transfers per year). Factors associated with increased risk of transfers included prior diagnoses of hip fracture (annual incidence rate ratio or IRR: 2.057, 95% confidence interval (CI): [1.240, 3.412]), dialysis (IRR: 1.717, 95% CI: [1.313, 2.246]), urinary tract infection (IRR: 1.755, 95% CI: [1.361, 2.264]), pneumonia (IRR: 1.501, 95% CI: [1.072, 2.104]), daily pain (IRR: 1.297, 95% CI: [1.055,1.594]), anaemia (IRR: 1.229, 95% CI [1.068, 1.414]) and chronic obstructive pulmonary disease (IRR: 1.168, 95% CI: [1.010,1.352]). Transfer rates were lower in residents who had orders reflecting preferences for comfort care (IRR: 0.79, 95% CI: [0.665, 0.936]). DISCUSSION younger nursing home residents may require specialised interventions to reduce hospital transfers; declining transfer rates with the oldest age groups may reflect preferences for comfort-focused care.
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Affiliation(s)
- Wanzhu Tu
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Biostatistics & Health Data Science, Indianapolis, IN 46202, USA
| | - Ruohong Li
- Department of Biostatistics & Health Data Science, Indianapolis, IN 46202, USA
| | - Timothy E Stump
- Department of Biostatistics & Health Data Science, Indianapolis, IN 46202, USA
| | - Nicole R Fowler
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Jennifer L Carnahan
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Justin Blackburn
- Department of Health Policy and Management, Indiana University Fairbanks School of Public Health, Indianapolis, IN 46202, USA
| | - Greg A Sachs
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Susan E Hickman
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN 46202, USA
| | - Kathleen T Unroe
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Braun RT, Jung HY, Casalino LP, Myslinski Z, Unruh MA. Association of Private Equity Investment in US Nursing Homes With the Quality and Cost of Care for Long-Stay Residents. JAMA HEALTH FORUM 2021; 2:e213817. [PMID: 35977267 PMCID: PMC8796926 DOI: 10.1001/jamahealthforum.2021.3817] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022] Open
Abstract
Question Is private equity acquisition of nursing homes associated with the quality or cost of care for long-stay nursing home residents? Findings In this cohort study with difference-in-differences analysis of 9864 US nursing homes, including 9632 residents in 302 nursing homes acquired by private equity firms and 249 771 residents in 9562 other for-profit nursing homes without private equity ownership, private equity acquisition of nursing homes was associated with higher costs and increases in emergency department visits and hospitalizations for ambulatory sensitive conditions. Meaning This study suggests that more stringent oversight and reporting on private equity ownership of nursing homes may be warranted. Importance Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. Objective To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. Design, Setting, and Participants In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity–acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Exposure Private equity acquisitions of 302 nursing homes between 2013 and 2017. Main Outcomes and Measures This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care–sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Results Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity–acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (−0.2 percentage points; 95% CI, −1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, −1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, −0.4 to 1.3 percentage points; P = .30). Conclusions and Relevance This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs.
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Affiliation(s)
- Robert Tyler Braun
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Hye-Young Jung
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Lawrence P. Casalino
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Zachary Myslinski
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Mark Aaron Unruh
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
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Facility and resident characteristics associated with variation in nursing home transfers: evidence from the OPTIMISTIC demonstration project. BMC Health Serv Res 2021; 21:492. [PMID: 34030672 PMCID: PMC8142645 DOI: 10.1186/s12913-021-06419-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/19/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Centers for Medicare and Medicaid Services (CMS) funded demonstration project to evaluate financial incentives for nursing facilities providing care for 6 clinical conditions to reduce potentially avoidable hospitalizations (PAHs). The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) site tested payment incentives alone and in combination with the successful nurse-led OPTIMISTIC clinical model. Our objective was to identify facility and resident characteristics associated with transfers, including financial incentives with or without the clinical model. METHODS This was a longitudinal analysis from April 2017 to June 2018 of transfers among nursing home residents in 40 nursing facilities, 17 had the full clinical + payment model (1726 residents) and 23 had payment only model (2142 residents). Using CMS claims data, the Minimum Data Set, and Nursing Home Compare, multilevel logit models estimated the likelihood of all-cause transfers and PAHs (based on CMS claims data and ICD-codes) associated with facility and resident characteristics. RESULTS The clinical + payment model was associated with 4.1 percentage points (pps) lower risk of all-cause transfers (95% confidence interval [CI] - 6.2 to - 2.1). Characteristics associated with lower PAH risk included residents aged 95+ years (- 2.4 pps; 95% CI - 3.8 to - 1.1), Medicare-Medicaid dual-eligibility (- 2.5 pps; 95% CI - 3.3 to - 1.7), advanced and moderate cognitive impairment (- 3.3 pps; 95% CI - 4.4 to - 2.1; - 1.2 pps; 95% CI - 2.2 to - 0.2). Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score above most stable (CHESS score 4) increased the risk of PAH by 7.3 pps (95% CI 1.5 to 13.1). CONCLUSIONS Multiple resident and facility characteristics are associated with transfers. Facilities with the clinical + payment model demonstrated lower risk of all-cause transfers compared to those with payment only, but not for PAHs.
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Gracner T, Agarwal M, Murali KP, Stone PW, Larson EL, Furuya EY, Harrison JM, Dick AW. Association of Infection-Related Hospitalization With Cognitive Impairment Among Nursing Home Residents. JAMA Netw Open 2021; 4:e217528. [PMID: 33890988 PMCID: PMC8065379 DOI: 10.1001/jamanetworkopen.2021.7528] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Hospitalizations for infections among nursing home (NH) residents remain common despite national initiatives to reduce them. Cognitive impairment, which markedly affects quality of life and caregiving needs, has been associated with hospitalizations, but the association between infection-related hospitalizations and long-term cognitive function among NH residents is unknown. OBJECTIVE To examine whether there are changes in cognitive function before vs after infection-related hospitalizations among NH residents. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Minimum Data Set 3.0 linked to Medicare hospitalization data from 2011 to 2017 for US nursing home residents aged 65 years or older who had experienced an infection-related hospitalization and had at least 2 quarterly Minimum Data Set assessments before and 4 or more after the infection-related hospitalization. Analyses were performed from September 1, 2019, to December 21, 2020. EXPOSURE Infection-related hospitalization lasting 1 to 14 days. MAIN OUTCOMES AND MEASURES Using an event study approach, associations between infection-related hospitalizations and quarterly changes in cognitive function among NH residents were examined overall and by sex, age, Alzheimer disease and related dementias (ADRD) diagnosis, and sepsis vs other infection-related diagnoses. Resident-level cognitive function was measured using the Cognitive Function Scale (CFS), with scores ranging from 1 (intact) to 4 (severe cognitive impairment). RESULTS Of the sample of 20 698 NH residents, 71.0% were women and 82.6% were non-Hispanic White individuals; the mean (SD) age at the time of transfer to the hospital was 82 (8.5) years. The mean CFS score was 2.17, and the prevalence of severe cognitive impairment (CFS score, 4) was 9.0%. During the first quarter after an infection-related hospitalization, residents experienced a mean increase of 0.06 points in CFS score (95% CI, 0.05-0.07 points; P < .001), or 3%. The increase in scores was greatest among residents aged 85 years or older vs younger residents by approximately 0.022 CFS points (95% CI, 0.004-0.040 points; P < .05). The prevalence of severe cognitive impairment increased by 1.6 percentage points (95% CI, 1.2-2.0 percentage points; P < .001), or 18%; the increases were observed among individuals with ADRD but not among those without it. After an infection-related hospitalization, cognition among residents who had experienced sepsis declined more than for residents who had not by about 0.02 CFS points (95% CI, 0.00-0.04 points; P < .05). All observed differences persisted without an accelerated rate of decline for at least 6 quarters after infection-related hospitalization. No differences were observed by sex. CONCLUSIONS AND RELEVANCE In this cohort study, infection-related hospitalization was associated with immediate and persistent cognitive decline among nursing home residents, with the largest increase in CFS scores among older residents, those with ADRD, and those who had experienced sepsis. Identification of NH residents at risk of worsened cognition after an infection-related hospitalization may help to ensure that their care needs are addressed to prevent further cognitive decline.
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Affiliation(s)
- Tadeja Gracner
- RAND Corporation, Arlington, Virginia
- Now with RAND Corporation, Santa Monica, California
| | - Mansi Agarwal
- Center for Health Policy, Columbia University School of Nursing, New York, New York
- Now with Washington University School of Medicine, St Louis, Missouri
| | - Komal P. Murali
- Center for Health Policy, Columbia University School of Nursing, New York, New York
| | - Patricia W. Stone
- Center for Health Policy, Columbia University School of Nursing, New York, New York
| | - Elaine L. Larson
- Columbia University School of Nursing, New York, New York
- Columbia University Mailman School of Public Health, New York, New York
| | - E. Yoko Furuya
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Temkin-Greener H, Yan D, Wang S, Cai S. Racial disparity in end-of-life hospitalizations among nursing home residents with dementia. J Am Geriatr Soc 2021; 69:1877-1886. [PMID: 33749844 DOI: 10.1111/jgs.17117] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/20/2021] [Accepted: 02/02/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Explore within and across nursing home (NH) racial disparities in end-of-life (EOL) hospitalizations for residents with Alzheimer's disease or related dementia (ADRD), and examine whether severe cognitive impairment influences these relationships. DESIGN Observational study merging, at the individual level, C2014-2017 national-level Minimum Data Set (MDS), Medicare Beneficiary Summary Files (MBSF), and Medicare Provider Analysis and Review (MedPAR). Nursing Home Compare (NHC) was also used. SETTING Long-stay residents who died in a NH or a hospital within 8 days of discharge. PARTICIPANTS Analytical sample included 665,033 decedent residents with ADRD in 14,595 facilities. MAIN OUTCOMES AND MEASURES The outcome was hospitalization within 30 days of death. Key independent variables were race, severe cognitive impairment, and NH-level proportion of black residents. Other covariates included socio-demographics, dual eligibility, hospice enrollment, and chronic conditions. Facility-level characteristics were also included (e.g. profit status, staffing hours, etc.). We fit linear probability models with robust standard errors, fixed and random effects. RESULTS Compared to whites, black decedents had a significantly (p < 0.01) higher risk of EOL hospitalizations (7.88%). Among those with severe cognitive impairment, whites showed a lower risk of hospitalizations (6.04%). But EOL hospitalization risk among blacks with severe cognitive impairment was still significantly elevated (β = 0.0494; p < 0.01). A comparison of the base model with the fixed and random-effects models showed statistically significant hospitalization risk by decedent's race both within and across facilities. CONCLUSIONS AND RELEVANCE We found disparities between black and white residents with ADRD both within and across facilities. The within-facility disparities may be due to residents' preferences and/or NH practices that contribute to differential treatment. The across facility differences point to the overall quality of care disparities in homes with a higher prevalence of black residents. Persistence of such systemic disparities among the most vulnerable individuals is extremely troubling.
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Affiliation(s)
- Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Di Yan
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sijiu Wang
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Harrison JM, Agarwal M, Stone PW, Gracner T, Sorbero M, Dick AW. Does Integration of Palliative Care and Infection Management Reduce Hospital Transfers among Nursing Home Residents? J Palliat Med 2021; 24:1334-1341. [PMID: 33605787 DOI: 10.1089/jpm.2020.0577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: An estimated 50% of nursing home (NH) residents experience hospital transfers in their last year of life, often due to infections. Hospital transfers due to infection are often of little clinical benefit to residents with advanced illness, for whom aggressive treatments are often ineffective and inconsistent with goals of care. Integration of palliative care and infection management (i.e., merging the goals of palliative care and infection management at end of life) may reduce hospital transfers for residents with advanced illness. Objectives: Evaluate the association between integration and (1) all-cause hospital transfers and (2) hospital transfers due to infection. Design: Cross-sectional observational study. Setting/Subjects: 143,223 U.S. NH residents, including 42,761 residents in the advanced stages of dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Measurement: Cross-sectional, nationally representative NH survey data (2017-2018) were combined with resident data from the Minimum Data Set 3.0 and Medicare inpatient data (2016-2017). NH surveys measured integration of palliative care and infection management using an index of 0-100. Logistic regression models were used to estimate the relationships between integration intensity (i.e., the degree to which NHs follow best practices for integration) and all-cause hospital transfer and transfer due to infection. Results: Among residents with advanced dementia, integration intensity was inversely associated with all-cause hospital transfer and transfer due to infection (p < 0.001). Among residents with advanced COPD, integration intensity was inversely associated with all-cause hospital transfer (p < 0.05) but not transfers due to infection. Among residents with advanced CHF, integration intensity was not associated with either outcome. Conclusions: NH policies aimed to promote integration of palliative care and infection management may reduce burdensome hospital transfers for residents with advanced dementia. For residents with advanced CHF and COPD, alternative strategies may be needed to promote best practices for infection management at end of life.
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Affiliation(s)
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, New York, USA
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Segelman M, Ingber MJ, Feng Z, Khatutsky G, Bercaw L, Gasdaska A, Huber B, Voltmer H. Treating in Place: Acute Care for Long-Stay Residents in Nursing Facilities Under a CMS Initiative. J Am Geriatr Soc 2020; 69:407-414. [PMID: 33184840 DOI: 10.1111/jgs.16901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/25/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Nursing facility (NF) residents are commonly hospitalized, and many of these hospitalizations may be avoidable. A Centers for Medicare & Medicaid Services (CMS) initiative enables participating NFs to bill Medicare for providing on-site acute care to long-stay residents diagnosed with one of six ambulatory care sensitive conditions (pneumonia, congestive heart failure, chronic obstructive pulmonary disease, dehydration, skin infection, and urinary tract infection) that account for many avoidable hospitalizations. This study describes the frequency of initiative-related treatment for the six conditions, both on site and in the hospital, and the health status of residents who were treated. DESIGN We used the Minimum Data Set V3.0 and Medicare data to identify eligible residents, detect on-site treatment under the initiative as well as in-hospital treatment both before and during the initiative, and measure health status. SETTING Participating NFs during fiscal years 2017 to 2018. PARTICIPANTS There were 47,202 long-stay NF residents from 260 facilities in seven states. INTERVENTION CMS initiative to reduce avoidable hospitalizations among NF residents-payment reform. MEASUREMENTS Percentage per year who received on-site treatment (2017-2018), and who received in-hospital treatment (2014-2018), for the six conditions. RESULTS Each year, approximately 20% of residents received treatment on site during 2017 to 2018, and under 10% received treatment in the hospital during 2014 to 2018, with little change over these years. Residents treated on site had less chronic illness than those treated in the hospital. CONCLUSION Although the initiative sought to reduce hospitalizations, in-hospital treatment for the six conditions did not substantially change after initiative implementation, despite substantial new billing for on-site treatment for those conditions. These findings suggest that many residents treated on site would likely not have been hospitalized even absent the initiative. The residents treated on site tended to have fewer chronic conditions than those treated in the hospital.
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Loomer L, Ogarek JA, Mitchell SL, Volandes AE, Gutman R, Gozalo PL, McCreedy EM, Mor V. Impact of an Advance Care Planning Video Intervention on Care of Short-Stay Nursing Home Patients. J Am Geriatr Soc 2020; 69:735-743. [PMID: 33159697 DOI: 10.1111/jgs.16918] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES To assess whether an advance care planning (ACP) video intervention impacts care among short-stay nursing home (NH) patients. DESIGN PRagmatic trial of Video Education in Nursing Homes (PROVEN) was a pragmatic cluster randomized clinical trial. SETTING A total of 360 NHs (N = 119 intervention, N = 241 control) owned by two healthcare systems. PARTICIPANTS A total of 2,538 and 5,290 short-stay patients with advanced dementia or cardiopulmonary disease (advanced illness) in the intervention and control arms, respectively; 23,302 and 50,815 short-stay patients without advanced illness in the intervention and control arms, respectively. INTERVENTION Five ACP videos were available on tablets or online. Designated champions at each intervention facility were instructed to offer a video to patients (or proxies) on admission. Control facilities used usual ACP practices. MEASUREMENTS Follow-up time was at most 100 days for each patient. Outcomes included hospital transfers per 1000 person-days alive and the proportion of patients experiencing more than one hospital transfer, more than one burdensome treatment (tube-feeding, parenteral therapy, invasive mechanical intervention, and intensive care unit admission), and hospice enrollment. Champions recorded whether a video was offered in the patients' electronic medical record. RESULTS There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention versus control groups with advanced illness (rate (95% confidence interval (CI)), 12.3 (11.6-13.1) vs 13.2 (12.5-13.7); rate difference: -0.8; 95% CI = -1.8-0.2)). There was a nonsignificant reduction in hospital transfers per 1000 person-days alive in the intervention versus control among short-stay patients without advanced illness. Secondary outcomes did not differ between groups among patients with and without advanced illness. Based on champion only reports 14.2% and 15.3% of eligible short-stay patients with and without advanced illness were shown videos, respectively. CONCLUSION An ACP video program did not significantly reduce hospital transfers, burdensome treatment, or hospice enrollment among short-stay NH patients; however, fidelity to the intervention was low.
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Affiliation(s)
- Lacey Loomer
- Department of Economics, Labovitz School of Business and Economics, Duluth, Minnesota, USA
| | - Jessica A Ogarek
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Susan L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Angelo E Volandes
- General Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Section of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Pedro L Gozalo
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
| | - Ellen M McCreedy
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Vincent Mor
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
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Houchens N, Gupta A. Quality and safety in the literature: September 2020. BMJ Qual Saf 2020; 29:780-784. [DOI: 10.1136/bmjqs-2020-011887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 06/27/2020] [Indexed: 11/04/2022]
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Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, McCreedy EM, Zhai R, Mor V. Advance Care Planning Video Intervention Among Long-Stay Nursing Home Residents: A Pragmatic Cluster Randomized Clinical Trial. JAMA Intern Med 2020; 180:1070-1078. [PMID: 32628258 PMCID: PMC7399750 DOI: 10.1001/jamainternmed.2020.2366] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Standardized, evidenced-based approaches to conducting advance care planning (ACP) in nursing homes are lacking. OBJECTIVE To test the effect of an ACP video program on hospital transfers, burdensome treatments, and hospice enrollment among long-stay nursing home residents with and without advanced illness. DESIGN, SETTING, AND PARTICIPANTS The Pragmatic Trial of Video Education in Nursing Homes was a pragmatic cluster randomized clinical trial conducted between February 1, 2016, and May 31, 2019, at 360 nursing homes (119 intervention and 241 control) in 32 states owned by 2 for-profit corporations. Participants included 4171 long-stay residents with advanced dementia or cardiopulmonary disease (hereafter referred to as advanced illness) in the intervention group and 8308 long-stay residents with advanced illness in the control group, 5764 long-stay residents without advanced illness in the intervention group, and 11 773 long-stay residents without advanced illness in the control group. Analyses followed the intention-to-treat principle. INTERVENTIONS Five 6- to 10-minute ACP videos were made available on tablet computers or online. Designated champions (mostly social workers) in intervention facilities were instructed to offer residents (or their proxies) the opportunity to view a video(s) on admission and every 6 months. Control facilities used usual ACP practices. MAIN OUTCOMES AND MEASURES Twelve-month outcomes were measured for each resident. The primary outcome was hospital transfers per 1000 person-days alive in the advanced illness cohort. Secondary outcomes included the proportion of residents with or without advanced illness experiencing 1 or more hospital transfer, 1 or more burdensome treatment, and hospice enrollment. To monitor fidelity, champions completed reports in the electronic record whenever they offered to show residents a video. RESULTS The study included 4171 long-stay residents with advanced illness in the intervention group (2970 women [71.2%]; mean [SD] age, 83.6 [9.1] years), and 8308 long-stay residents with advanced illness in the control group (5857 women [70.5%]; mean [SD] age, 83.6 [8.9] years), 5764 long-stay residents without advanced illness in the intervention group (3692 women [64.1%]; mean [SD] age, 81.5 [9.2] years), and 11 773 long-stay residents without advanced illness in the control group (7467 women [63.4%]; mean [SD] age, 81.3 [9.2] years). There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention vs control groups (rate [SE], 3.7 [0.2]; 95% CI, 3.4-4.0 vs 3.9 [0.3]; 95% CI, 3.6-4.1; rate difference [SE], -0.2 [0.3]; 95% CI, -0.5 to 0.2). Secondary outcomes did not significantly differ between trial groups among residents with and without advanced illness. Based on champions' reports, 912 of 4171 residents with advanced illness (21.9%) viewed ACP videos. Facility-level rates of showing ACP videos ranged from 0% (14 of 119 facilities [11.8%]) to more than 40% (22 facilities [18.5%]). CONCLUSIONS AND RELEVANCE This study found that an ACP video program was not effective in reducing hospital transfers, decreasing burdensome treatment use, or increasing hospice enrollment among long-stay residents with or without advanced illness. Intervention fidelity was low, highlighting the challenges of implementing new programs in nursing homes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02612688.
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Affiliation(s)
- Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Angelo E Volandes
- Section of General Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Lacey Loomer
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ellen M McCreedy
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ruoshui Zhai
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Affairs Medical Center, Providence, Rhode Island
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Anderson TS, Marcantonio ER, McCarthy EP, Herzig SJ. National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia. J Am Geriatr Soc 2020; 68:2240-2248. [PMID: 32700399 DOI: 10.1111/jgs.16636] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/09/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND/OBJECTIVES Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking. DESIGN Retrospective cohort study using the National Inpatient Sample from 2012 to 2016. SETTING U.S. acute care hospitals. PARTICIPANTS A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia. MEASUREMENTS Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs. RESULTS The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community. CONCLUSION The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020.
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Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ellen P McCarthy
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Shoshana J Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Affiliation(s)
- David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Providence Veterans Administration Medical Center, Providence, Rhode Island
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Unroe KT, Caterino JM, Stump TE, Tu W, Carnahan JL, Vest JR, Sachs GA, Hickman SE. Long‐Stay Nursing Facility Resident Transfers: Who Gets Admitted to the Hospital? J Am Geriatr Soc 2020; 68:2082-2089. [DOI: 10.1111/jgs.16633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/06/2020] [Accepted: 05/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Kathleen T. Unroe
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine and Internal Medicine The Ohio State University School of Medicine Columbus Ohio USA
| | - Timothy E. Stump
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
| | - Wanzhu Tu
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Jennifer L. Carnahan
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Joshua R. Vest
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
- Department of Health Policy and Management Indiana University Richard M. Fairbanks School of Public Health at Indiana University ‐ Purdue University Indianapolis Indianapolis Indiana USA
| | - Greg A. Sachs
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Susan E. Hickman
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
- Department of Community and Health Systems Indiana University School of Nursing Indianapolis Indiana USA
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White E, Woodford E, Britton J, Newberry LW, Pabico C. Nursing practice environment and care quality in nursing homes. Nurs Manag (Harrow) 2020; 51:9-12. [PMID: 32472854 DOI: 10.1097/01.numa.0000662656.07901.a8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
A case study of the Pathway to Excellence in Long-Term Care model.
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Affiliation(s)
- Elizabeth White
- Elizabeth White is a postdoctoral fellow in the Center for Gerontology and Healthcare Research at the Brown University School of Public Health in Providence, R.I. At Genesis Healthcare in Pottsville, Pa. Erin Woodford is the director of population health for division II and III and Julie Britton is the senior vice president of clinical operations. At the American Nurses Credentialing Center in Silver Spring, Md., Lynn Newberry is the education and outreach program manager and Christine Pabico is the director of the Pathway to Excellence program
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Estabrooks CA, Straus SE, Flood CM, Keefe J, Armstrong P, Donner GJ, Boscart V, Ducharme F, Silvius JL, Wolfson MC. Restoring trust: COVID-19 and the future of long-term care in Canada. Facets (Ott) 2020. [DOI: 10.1139/facets-2020-0056] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The Royal Society of Canada Task Force on COVID-19 was formed in April 2020 to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19. The Task Force established a series of working groups to rapidly develop policy briefings, with the objective of supporting policy makers with evidence to inform their decisions. This paper reports the findings of the COVID-19 Long-Term Care (LTC) working group addressing a preferred future for LTC in Canada, with a specific focus on COVID-19 and the LTC workforce. First, the report addresses the research context and policy environment in Canada’s LTC sector before COVID-19 and then summarizes the existing knowledge base for integrated solutions to challenges that exist in the LTC sector. Second, the report outlines vulnerabilities exposed because of COVID-19, including deficiencies in the LTC sector that contributed to the magnitude of the COVID-19 crisis. This section focuses especially on the characteristics of older adults living in nursing homes, their caregivers, and the physical environment of nursing homes as important contributors to the COVID-19 crisis. Finally, the report articulates principles for action and nine recommendations for action to help solve the workforce crisis in nursing homes.
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Affiliation(s)
| | - Sharon E. Straus
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Janice Keefe
- Department of Family Studies and Gerontology, Mount Saint Vincent University, Halifax, NS, Canada
| | - Pat Armstrong
- Department of Sociology, York University, Toronto, ON, Canada
| | - Gail J. Donner
- Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Véronique Boscart
- CIHR/Schlegel Industrial Research Chair for Colleges in Seniors Care, Conestoga College, Kitchener, ON, Canada
| | | | - James L. Silvius
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael C. Wolfson
- School of Epidemiology and Public Health and Faculty of Law, University of Ottawa, Ottawa, ON, Canada
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