Association of dementia with early rehospitalization among Medicare beneficiaries

Determinants of hospital readmissions in older people with dementia: a narrative review

INTRODUCTION

Over 50% of hospitalised older people with dementia have multimorbidity, and are at an increased risk of hospital readmissions within 30 days of their discharge. Between 20-40% of these readmissions may be preventable. Current research focuses on the physical causes of hospital readmissions. However, older people with dementia have additional psychosocial factors that are likely to increase their risk of readmissions. This narrative review aimed to identify psychosocial determinants of hospital readmissions, within the context of known physical factors.

METHODS

Electronic databases MEDLINE, EMBASE, CINAHL and PsychInfo were searched from inception until July 2022 and followed up in February 2024. Quantitative and qualitative studies in English including adults aged 65 years and over with dementia, their care workers and informal carers were considered if they investigated hospital readmissions. An inductive approach was adopted to map the determinants of readmissions. Identified themes were described as narrative categories.

RESULTS

Seventeen studies including 7,194,878 participants met our inclusion criteria from a total of 6369 articles. Sixteen quantitative studies included observational cohort and randomised controlled trial designs, and one study was qualitative. Ten studies were based in the USA, and one study each from Taiwan, Australia, Canada, Sweden, Japan, Denmark, and The Netherlands. Large hospital and insurance records provided data on over 2 million patients in one American study. Physical determinants included reduced mobility and accumulation of long-term conditions. Psychosocial determinants included inadequate hospital discharge planning, limited interdisciplinary collaboration, socioeconomic inequalities among ethnic minorities, and behavioural and psychological symptoms. Other important psychosocial factors such as loneliness, poverty and mental well-being, were not included in the studies.

CONCLUSION

Poorly defined roles and responsibilities of health and social care professionals and poor communication during care transitions, increase the risk of readmission in older people with dementia. These identified psychosocial determinants are likely to significantly contribute to readmissions. However, future research should focus on the understanding of the interaction between a host of psychosocial and physical determinants, and multidisciplinary interventions across care settings to reduce hospital readmissions.

Access to preferred skilled nursing facilities: Transitional care pathways for patients with Alzheimer's disease and related dementias

OBJECTIVE

The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high-volume preferred skilled nursing facility (SNF) partners.

DATA SOURCES

The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017-2019.

STUDY DESIGN

We model and compare the estimated effect of facility "preferredness" on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics.

DATA COLLECTION

Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019.

PRINCIPAL FINDINGS

Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, p < 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (p < 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital-SNF relationship, and (c) comparing patients with more versus less advanced ADRD.

CONCLUSIONS

Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high-volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems).

Risk Selection and Care Fragmentation at Medicare Accountable Care Organizations for Patients With Dementia

BACKGROUND

Patients with dementia are a growing and vulnerable population within Medicare. Accountable care organizations (ACOs) are becoming Medicare's dominant care model, but ACO enrollment and care patterns for patients with dementia are unknown.

OBJECTIVE

The aim of this study was to compare differences in ACO enrollment for patients with versus without dementia, and in risk profiles and ambulatory care among patients with dementia by ACO enrollment status.

RESEARCH DESIGN

Cohort study assessing the relationships between patient dementia, following-year ACO enrollment, and ambulatory care patterns.

SUBJECTS

A total of 13,362 (weighted: 45, 499,049) person-years for patients [2761 (weighted: 6,312,304) for dementia patients] ages 65 years and above in the 2015-2019 Medicare Current Beneficiary Survey.

MEASURES

We assessed differences in ACO enrollment rates for patients with versus without dementia, and in dementia-relevant ambulatory care visit rates and validated care fragmentation indices among patients with dementia by ACO enrollment status.

RESULTS

Patients with versus without dementia were less likely to be enrolled in (38.3% vs. 44.6%, P<0.001), and more likely to exit (21.1% vs. 13.7%, P<0.01) ACOs. Among patients with dementia, those enrolled versus not enrolled in ACOs had a more favorable social and health risk profile on 6 of 16 measures (P<0.05). There were no differences in rates of dementia-relevant, primary, or specialty care visits. ACO enrollment was associated with 45.7% higher wellness visit rates (P<0.001), and 13.4% more fragmented primary care (P<0.01) spread across 8.7% more distinct physicians (P<0.05).

CONCLUSION

Medicare ACOs are less likely to enroll and retain patients with dementia than other patients and provide more fragmented primary care without providing additional dementia-relevant ambulatory care visits.

Transitional Care Model in Germany: Findings from an economic analysis of a randomized controlled trial

INTRODUCTION

The statutory discharge management system in German hospitals does not provide adequate transitional care for geriatric patients. The American Transitional Care Model (TCM), where a qualified professional supports the patient for a period before, during, and after discharge, could help to address this problem. In this study, we compared both approaches from an economic perspective. Our research questions were: (1) How do treatment costs per person differ when geriatric patients are supported according to the TCM compared with routine discharge management? (2) What are the intervention costs?

METHODS

The present economic analysis was part of a randomized controlled trial conducted at a hospital in Germany. In this study, geriatric patients in the intervention group received care according to TCM and those in the control group received routine care. We obtained data from the hospital and a health insurance company. In a cost-cost analysis, we compared the treatment costs per patient incurred in both study groups. In cases where higher costs occurred in the intervention group, we also conducted a cost-utility analysis, using the 12-Item Short Form Survey questionnaire to collect quality-of-life data for the Quality Adjusted Life Years calculation. Intervention costs were calculated on the basis of staff salaries, working hours, and the cost of acquiring the necessary equipment.

RESULTS

The intervention group consisted of 109 geriatric patients, the control group of 119. The average quality-of-life score was slightly higher in the intervention group, but the difference was not significant. On average, the intervention group was less expensive. However, for individual cost types (e.g., rehabilitation), the intervention group incurred higher costs than the control group. The differences between the study groups were not significant for all cost types (p > 0.05). Intervention costs were estimated to be approximately 800 euros per patient.

DISCUSSION

The TCM approach leads to savings. However, the quantum of savings will depend on intervention costs, which vary in practice. After outlier exclusion, an unfavorable incremental cost-effectiveness ratio is observed for the TCM approach.

CONCLUSION

From an economic perspective, TCM in its present form provides no additional value to patient care compared with routine discharge management. However, we see an urgent need to optimize the existing discharge management system to ensure better transitional care for those affected. Therefore, we recommend that different TCM components should be tested in further studies to address the questions that could not be clarified in the present study.

Primary care patterns among dual eligibles with Alzheimer's disease and related dementias

BACKGROUND

Primary care is essential for persons with Alzheimer's disease and related dementias (ADRD). Prior research suggests that the propensity to provide high-quality, continuous primary care varies by provider setting, but the settings used by Medicare-Medicaid dual-eligibles with ADRD have not been described at the population level.

METHODS

Using 2012-2018 Medicare data, we identified dual-eligibles with ADRD. For each person-year, we identified primary care visits occurring in six settings. We calculated descriptive statistics for beneficiaries with a majority of visits in each setting, and conducted a k-means cluster analysis to determine utilization patterns, using the standardized count of primary care visits in each setting.

RESULTS

Each year from 2012 to 2018, at least 45.6% of dual-eligibles with ADRD received a majority of their primary care in nursing facilities, while at least 25.2% did so in physician offices. Over time, the share relying on nursing facilities for primary care decreased by 5.2 percentage points, offset by growth in Federally Qualified Health Centers (FQHCs) and miscellaneous settings (2.3 percentage points each). Dual-eligibles relying on nursing facilities had more annual primary care visits (16.1) than those relying on other settings (range: 6.8-10.7 visits). Interpersonal care continuity was also higher in nursing facilities (97.0%) and physician offices (87.9%) than in FQHCs (54.2%), rural health clinics (RHCs, 46.6%), or hospital-based clinics (56.8%). Among dual-eligibles without care continuity, 82.7% were assigned to a cluster with few primary care visits.

CONCLUSIONS

A trend toward care in different settings likely reflects improved access to patient-centered primary care. Low rates of interpersonal care continuity in FQHCs, RHCs, and physician offices may warrant concern, unless providers in these settings function as a care team. Nonetheless, every healthcare system encounter presents an opportunity to designate a primary care provider for dual-eligibles with ADRD who use little or no primary care.

Readmission Rates and Episode Costs for Alzheimer Disease and Related Dementias Across Hospitals in a Statewide Collaborative

IMPORTANCE

There has been a paucity of research examining the risk and cost of readmission among patients with Alzheimer disease and related dementias (ADRD) after a planned hospitalization for a broad set of medical and surgical procedures.

OBJECTIVE

To examine 30-day readmission rates and episode costs, including readmission costs, for patients with ADRD compared with their counterparts without ADRD across Michigan hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used 2012 to 2017 Michigan Value Collaborative data across different medical and surgical services stratified by ADRD diagnosis. A total of 66 676 admission episodes of care that occurred between January 1, 2012, and June 31, 2017, were identified for patients with ADRD using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes for ADRD, along with 656 235 admission episodes in patients without ADRD. Using a generalized linear model framework, this study risk adjusted, price standardized, and performed episode payment winsorization. Payments were risk adjusted for age, sex, Hierarchical Condition Categories, insurance type, and prior 6-month payments. Selection bias was accounted for using multivariable logistic regression with propensity score matching without replacement using calipers. Data analysis was performed from January to December 2019.

EXPOSURE

Presence of ADRD.

MAIN OUTCOMES AND MEASURES

Main outcomes were 30-day readmission rate at the patient and county levels, 30-day readmission cost, and 30-day total episode cost across 28 medical and surgical services.

RESULTS

The study included 722 911 hospitalization episodes, of which 66 676 were related to patients with ADRD (mean [SD] age, 83.4 [8.6] years; 42 439 [63.6%] female) and 656 235 were related to patients without ADRD (mean [SD] age, 66.0 [15.4] years; 351 246 [53.5%] female). After propensity score matching, 58 629 hospitalization episodes were included for each group. Readmission rates were 21.5% (95% CI, 21.2%-21.8%) for patients with ADRD and 14.7% (95% CI, 14.4%-15.0%) for patients without ADRD (difference, 6.75 percentage points; 95% CI, 6.31-7.19 percentage points). Cost of 30-day readmission was $467 higher (95% CI of difference, $289-$645) among patients with ADRD ($8378; 95% CI, $8263-$8494) than those without ($7912; 95% CI, $7776-$8047). Across all 28 service lines examined, total 30-day episode costs were $2794 higher for patients with ADRD vs patients without ADRD ($22 371 vs $19 578; 95% CI of difference, $2668-$2919).

CONCLUSIONS AND RELEVANCE

In this cohort study, patients with ADRD had higher readmission rates and overall readmission and episode costs than their counterparts without ADRD. Hospitals may need to be better equipped to care for patients with ADRD, especially in the postdischarge period. Considering that any type of hospitalization may put patients with ADRD at a high risk of 30-day readmission, judicious preoperative assessment, postoperative discharge, and care planning are strongly advised for this vulnerable patient population.

Dementia-related agitation: a 6-year nationwide characterization and analysis of hospitalization outcomes

OBJECTIVES

To characterize all hospitalizations held in mainland Portugal (2010-2015) with dementia-related agitation based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding, and to investigate whether there is a relationship between agitation and hospitalization outcomes.

METHODS

A retrospective observational study was conducted using an administrative dataset containing data from all mainland Portuguese public hospitals. Only hospitalization episodes for patients aged over 65 years who have received a dementia diagnosis ascertained by an ICD-9-CM code of dementia with behavioral disturbance (294.11 and 294.21) and dementia without behavioral disturbance (294.10 and 294.20) were selected. Episodes were further grouped according to the presence of an agitation code. For each episode, demographic data and hospitalization outcomes, including length of stay (LoS), in-hospital mortality, discharge destination and all-cause hospital readmissions, were sourced from the dataset. Comparative analyses were performed and multivariable logistic methods were used to estimate the adjusted associations between agitation (exposure) and outcomes.

RESULTS

Overall, 53,156 episodes were selected, of which 6,586 had an agitation code. These were mostly related to male, younger inpatients (mean 81.19 vs. 83.29 years, p < 0.001), had a higher comorbidity burden, stayed longer at the hospital (median 9.00 vs. 8.00 days, p < 0.001) and frequently ended being transferred to another facility with inpatient care. Agitation was shown to independently increase LoS (aOR = 1.385; 95%CI:1.314-1.461), but not the risk of a fatal outcome (aOR = 0.648; 95%CI:0.600-0.700).

CONCLUSION

These results support the importance of detecting and managing agitation early on admission, since its prompt management may prevent lengthy disruptive hospitalizations.

[Reasons for hospitalization of people with dementia-A scoping review]

BACKGROUND

Hospitalization represents a high burden for people with dementia, which can accelerate the decline of cognitive and motor skills. Behavioral changes and orientation problems may be increased in people with dementia during hospitalization. Some hospitalizations are potentially preventable by improved outpatient care.

OBJECTIVE

To provide an up to date overview of the most common reasons for hospitalization of people with dementia or mild cognitive impairment.

MATERIAL AND METHODS

A systematic literature search was conducted in the databases PubMed®, CINAHL and PsycINFO® in May 2020 to conduct the scoping review. Studies in German and English published between July 2010 and May 2020 were included.

RESULTS

The most common reasons for hospitalization, which were named in the 14 included studies, were infectious diseases, especially respiratory infections and urinary tract infections, cardiovascular diseases (in general or specific, e.g. heart failure) and injuries, poisoning, fractures and falls, and gastrointestinal diseases.

CONCLUSION

Most of the most common reasons for hospitalization are ambulatory care-sensitive hospital cases. Strengthening outpatient care for people with dementia may help prevent hospitalizations.

Association of Diagnosed Dementia with Post-discharge Mortality and Readmission Among Hospitalized Medicare Beneficiaries

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.

Multi-dimensional relationships among dementia, depression and prescribed drugs in England and Wales hospitals

Background

 Dementia is a group of symptoms that largely affects older people. The majority of patients face behavioural and psychological symptoms (BPSD) during the course of their illness. Alzheimer’s disease (AD) and vascular dementia (VaD) are two of the most prevalent types of dementia. Available medications provide symptomatic benefits and provide relief from BPSD and associated health issues. However, it is unclear how specific dementia, antidepressant, antipsychotic, antianxiety, and mood stabiliser drugs, used in the treatment of depression and dementia subtypes are prescribed in hospital admission, during hospital stay, and at the time of discharge. To address this, we apply multi-dimensional data analytical approaches to understand drug prescribing practices within hospitals in England and Wales.

Methods

We made use of the UK National Audit of Dementia (NAD) dataset and pre-processed the dataset. We evaluated the pairwise Pearson correlation of the dataset and selected key data features which are highly correlated with dementia subtypes. After that, we selected drug prescribing behaviours (e.g. specific medications at the time of admission, during the hospital stay, and upon discharge), drugs and disorders. Then to shed light on the relations across multiple features or dimensions, we carried out multiple regression analyses, considering the number of dementia, antidepressant, antipsychotic, antianxiety, mood stabiliser, and antiepileptic/anticonvulsant drug prescriptions as dependent variables, and the prescription of other drugs, number of patients with dementia subtypes (AD/VaD), and depression as independent variables.

Results

In terms of antidepressant drugs prescribed in hospital admission, during stay and discharge, the number of sertraline and venlafaxine prescriptions were associated with the number of VaD patients whilst the number of mirtazapine prescriptions was associated with frontotemporal dementia patients. During admission, the number of lamotrigine prescriptions was associated with frontotemporal dementia patients, and with the number of valproate and dosulepin prescriptions. During discharge, the number of mirtazapine prescriptions was associated with the number of donepezil prescriptions in conjunction with frontotemporal dementia patients. Finally, the number of prescriptions of donepezil/memantine at admission, during hospital stay and at discharge exhibited positive association with AD patients.

Conclusion

Our analyses reveal a complex, multifaceted set of interactions among prescribed drug types, dementia subtypes, and depression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01892-9.

Clinical and Demographic Profiles of Home Care Patients With Alzheimer's Disease and Related Dementias: Implications for Information Transfer Across Care Settings

Home health care (HHC) clinicians serving individuals with Alzheimer's disease and related dementias (ADRD) do not always have information about the person's ADRD diagnosis, which may be used to improve the HHC plan of care. This retrospective cohort study examined characteristics of 56,652 HHC patients with varied documentation of ADRD diagnoses. Data included clinical assessments and Medicare claims for a 6-month look-back period and 4-year follow-up. Nearly half the sample had an ADRD diagnosis observed in the claims either prior to or following the HHC admission. Among those with a prior diagnosis, 63% did not have it documented on the HHC assessment; the diagnosis may not have been known to the HHC team or incorporated into the care plan. Patients with ADRD had heightened risk for adverse outcomes (e.g., urinary tract infection and aspiration pneumonia). Interoperable data across health care settings should include ADRD-specific elements about diagnoses, symptoms, and risk factors.

[Discharge management in German hospitals for cognitively impaired, older people-a scoping review]

BACKGROUND

In German hospitals approximately 40% of all patients over the age of 65 years are cognitively impaired (MmkB). After discharge from hospital it is particularly important for MmkB that the transition to domestic life is organized as seamlessly and as well-coordinated as possible.

OBJECTIVE

The aim of the study was to determine the existing evidence on discharge management (EM) in MmkB and people with dementia (MmD). Furthermore, the study examined the necessity of an intersectoral concept for MmkB.

MATERIAL AND METHODS

Based on a scoping review a total of 102 publications were identified, of which 6 articles were finally used for the evaluation.

RESULTS

The article provides an overview of the current care of MmkB in acute care hospitals in Germany. General information on EM in hospitals was given in three of the six publications included. Information on special discharge and care management for MmkB and MmD was contained in five out of six papers.

DISCUSSION

The article illustrates significant gaps in the hospital care for older MmkB, in particular at the interface of discharge management and demonstrates the need for new care models. To what extent these new care models can be structurally, procedurally and systemically embedded in the standard care and financed, is an open and unexplored question.

Recruiting and Retaining Dyads of Hospitalized Persons with Dementia and Family Caregivers

Persons with dementia have high rates of hospitalization, and along with their caregivers commonly experience negative hospital outcomes. The recruitment and retention of acutely ill older adults with dementia and caregivers can pose a challenge to investigators and threaten the validity of findings. The challenges encountered in an ongoing cluster randomized clinical trial in dyads of hospitalized persons with dementia and family care partners are described. The trial tests the efficacy of a nurse-family partnership model that aims to improve the following: (a) the physical and cognitive recovery in hospitalized persons with dementia, and (b) caregiver preparedness and anxiety. Strategies that address challenges include careful preplanning and preparation with the hospital site, strong communication with dyads and between team members, and honoring preferences and needs related to communication.

A Scoping Review of Care Trajectories across Multiple Settings for Persons with Dementia

Multiple transitions across care settings can be disruptive for older adults with dementia and their care partners, and can lead to fragmented care with adverse outcomes. This scoping review was conducted to identify and classify care trajectories across multiple settings for people with dementia, and to understand the prevalence of multiple transitions and associated factors at the individual and organizational levels. Searches of three databases, limited to peer-reviewed studies published between 2007 and 2017, provided 33 articles for inclusion. We identified 26 distinct care trajectories. Common trajectories involved hospital readmission or discharge from hospital to long-term care. Factors associated with transitions were identified mainly at the level of demographic and medical characteristics. Findings suggest a need for investing in stronger community-based systems of care that may reduce transitions. Further research is recommended to address knowledge gaps about complex and longitudinal care trajectories and trajectories experienced by sub-populations of people living with dementia.

Describing people with cognitive impairment and their complex treatment needs during routine care in the hospital - cross-sectional results of the intersec-CM study

BACKGROUND

Cognitive impairment is an important determinant in health care. In the acute hospital setting cognition has a strong impact on treatment and care. Cognitive impairment can negatively affect diagnostics and treatment success. However, little is known about the individual situation and specific risks of people with cognitive impairments during hospital stays. The aim of the present research is to describe and analyze the treatment needs of people with cognitive impairments in acute hospital care.

METHODS

The analyses use baseline data of the ongoing multisite, longitudinal, randomized controlled intervention trial intersec-CM (Supporting elderly people with cognitive impairment during and after hospital stays with Intersectoral Care Management), which recruited 402 participants at baseline. We assessed sociodemographic aspects, cognitive status, functional status, frailty, comorbidities, level of impairment, formal diagnosis of dementia, geriatric diagnoses, delirium, depression, pharmacological treatment, utilization of health care services and health care related needs.

RESULTS

The sample under examination had been on average mildly cognitively impaired (MMSE M = 22.3) and had a mild to moderate functional impairment (Barthel Index M = 50.4; HABAM M = 19.1). The Edmonton Frail Scale showed a mean of 7.4 and half of the patients (52.3%) had been assigned a care level. About 46.9% had a geriatric diagnosis, 3.0% had a diagnosis of dementia. According to DSM-V 19.2% of the patients had at least one main symptom of depression. The mean number of regularly taken drugs per patient was 8.2. Utilization of health care services prior to the hospital stay was rather low. On average, the sample showed 4.38 care related needs in general, of which 0.60 needs were unaddressed at the time of assessment.

CONCLUSIONS

Descriptive analyses highlight an in-depth insight into impairments and different care needs of people with cognitive impairments. The results emphasize the need for gender-specific analyses as well as an increased attention to the heterogeneity of needs of people with cognitive impairments related to specific wards, settings and regions where they are admitted. Our results indicate also that people with cognitive impairments represent a high proportion of older patients in acute hospital care.

TRIAL REGISTRATION

The intersec-CM trial is registered at ClinicalTrials.gov ( NCT03359408 ).

Effectiveness of a Geriatric Emergency Medicine Unit for the Management of Neurocognitive Disorders in Older Patients: Results of the MUPACog Study

INTRODUCTION

The prevalence of neurocognitive disorders (NCDs) increases with age and is associated with cognitive impairment. Older patients with NCD admitted to the emergency department (ED) are readmitted after discharge to home more often than those without NCD. Comprehensive geriatric assessment (CGA) is effective for improving clinical outcomes in older patients; however, the usefulness of CGA for older patients with NCD admitted to the ED has not been investigated. The main objective of our study is to assess the effectiveness of a geriatric emergency medicine unit (GEMU) for elderly patients with NCD admitted to the ED.

METHODS

This historical cohort study included patients aged 75 years and older with NCD admitted to the ED of Limoges University Hospital in France over a 4-year period. We compared patients treated in our hospital's GEMU, the MUPA unit (exposed group), and patients who received standard care by emergency physicians (control group). The primary end point was the incidence of 30-day readmissions.

RESULTS

The study included 801 patients admitted to the ED between January 1, 2015, and December 31, 2018 (400 in the exposed group). Of those, 72.5% were female, and the mean age was 87 ± 5 years. After adjusting for confounding factors, the 30-day readmission rate was significantly associated with the MUPA unit intervention.

CONCLUSION

CGA in a GEMU improved health outcomes in elderly patients with NCD in the ED. We recommend that all EDs include a geriatric team, such as the MUPA unit, to treat all patients with NCD admitted to the ED.

"Getting to Know Them": Person-Centered Care for Patients With Dementia in Acute Care

Older adults with dementia are reported to have twice as many hospital stays as their age-matched counterparts without dementia. Acute care hospitals are generally not equipped to provide best care for persons with dementia. The purpose of the current qualitative study was to gain an understanding of the needs and perspectives of nursing staff and patient care technicians regarding delivering person-centered care (PCC) to patients with dementia. Nine focus groups (N = 49) were conducted. Participants discussed the importance of "getting to know them" as the basis for their care. Several themes emerged that served to support or detract from providing PCC: (a) communication, (b) education, and (c) care environment. Findings from this study support the desire of nurses and patient care technicians to provide PCC, highlight challenges, and indicate needed system-level changes to education, communication, and the care environment to support best practices. [Journal of Gerontological Nursing, 47(5), 37-44.].

Pain Incidence, Treatment, and Associated Symptoms in Hospitalized Persons with Dementia

BACKGROUND

Moderate to severe pain has been frequently reported in hospitalized older adults. Pain in hospitalized persons with dementia within the context of other common symptoms, functional decline, delirium, and behavioral and psychological symptoms of dementia (BPSD), has received little attention.

AIMS

Describe the incidence of pain, the pharmacologic management of pain, and the association of pain with physical function, delirium, and BPSD in hospitalized persons with dementia.

DESIGN

Descriptive, cross-sectional study.

SETTING

Six medical units in three hospitals.

PARTICIPANTS

Baseline data from 299 hospitalized persons with dementia enrolled in the Family-centered Function-focused Care (Fam-FFC) cluster randomized trial.

METHODS

Descriptive analyses of pain used the Pain Assessment in Advanced Dementia (PAINAD) scale and the use of medication for pain management. Linear regression analyses tested relationships between pain and:1) physical function (Barthel Index), 2) delirium severity (Confusion Assessment Method Severity Short Form) and 3) BPSD severity (Neuropsychiatric Inventory- Questionnaire).

RESULTS

The majority of the sample was female (61.9%), non-Hispanic (98%), and Black (53.2%), with a mean age of 81.58 (SD=8.54).Of the 299 patients, 166 (56%) received pain medication. Of the 108 individuals who demonstrated pain, 40% (n=43) did not receive pain medication. When controlling for age, gender, cognition, and comorbidities, pain was significantly associated with function, delirium severity, and BPSD severity.

CONCLUSIONS

Results suggest that pain may be undertreated in hospitalized persons with dementia, and should be considered upon admission to optimize function, decrease delirium, and prevent or decrease BPSD.

Dementia identified as a risk factor for infection-related hospital contacts in a national, population-based and longitudinal matched-cohort study

The aim of this study was to investigate the association between incident dementia and rates of infection-related hospital contacts. We conducted a registry- and population-based matched-cohort study of all Danish residents who were born in or before 1950, included from 1 January 2000 or their 65th birthday (whichever came later), who were alive and resided in Denmark at the start of the study, excluding those who had received a dementia diagnosis before 1 January 2000 or their 65th birthday (n = 1,712,100). A total of 129,660 people (403,744 person years) with incident dementia were matched with 297,476 people (1,918,784 person years) without dementia. Incidence rate ratios (IRRs) of infection-related hospital contacts were calculated using Poisson regression, by infection type, sex and age. The IRR for any infection-related contact in dementia was 1.5, was highest for nervous and urinary system infections and sepsis, decreased with increasing age and was higher in men. More people with than without dementia had contacts five years before the index date. Our findings show that dementia is a risk factor for infection-related hospital contacts and infections might be an early sign of dementia.

Intersectoral care management for older people with cognitive impairment during and after hospital stays [intersec-CM]: study protocol for a process evaluation within a randomised controlled trial

Background

In the healthcare system in Germany, different institutions and actors play specific roles in the discharge and transition of patients from hospitals into primary care (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, Wettbewerb an der Schnittstelle zwischen ambulanter und stationärer Gesundheitsversorgung, 2012). However, there are shortcomings in these intersectoral transitions. Especially in older people with cognitive impairment (PCI), discharge management often lacks coordination and cooperation between healthcare providers. This frequently results in higher rates of unscheduled readmission. The project intersec-CM is a randomised controlled trial (RCT) that aims to explore up to what extent an intersectoral care management (ICM) can improve this transition. This ICM is delivered by nurses with special training in care management. The objective of this paper is to describe a mixed-methods process evaluation of the intersectoral care management intervention and the factors that facilitate and inhibit its implementation.

Methods

Different study designs for process evaluations from previous literature were collected and analysed according to the dimension implementation fidelity, satisfaction with the intervention, feasible transfer into routine care, optimum point of time, frequency and execution of the intervention, and context factors.

Results

The actor-network theory was chosen as the theoretic framework for the process evaluation. Based on this theory, a mixed-methods design was developed to combine and integrate qualitative and quantitative evaluation methods. The qualitative part includes semi-structured interviews using topic guides (phase 1) and later in-depth interviews with narrative portions (phase 3), which will be analysed by using the qualitative content analysis according to Kuckartz. The quantitative survey (phase 2) is conducted with standardised questionnaires.

Discussion

Challenges in data collection include the development of interview guidelines, which require different terminologies depending on every specific actor targeted in the intervention. Conducting the interviews, there is a risk of misunderstanding the older PCI by the interviewer and vice versa. However, the combination of qualitative and quantitative approaches as different techniques of process evaluation may help to capture, integrate and analyse data on different dimensions of the intervention.

Conclusions

The results of our process evaluation may serve as an implementation guideline for intersectoral care management in the German healthcare system. Furthermore, the approach to evaluate the process of a complex intervention in health care for older PCI may serve as a stimulus to broaden the evidence base also of other complex intervention studies to improve health care for this vulnerable group.

The study was ethically approved by the Ethics Committee of the Ernst-Moritz-Arndt University of Greifswald. The study has been registered at the U.S. National Library of Medicine.

Trial registration

ClinicalTrials.gov NCT03359408. Registered on 2 December 2017. The approximate date when recruitment to the process evaluation of the study will be completed is 31 May 2021.

180-day readmission risk model for older adults with acute myocardial infarction: the SILVER-AMI study

OBJECTIVE

To develop a 180-day readmission risk model for older adults with acute myocardial infarction (AMI) that considered a broad range of clinical, demographic and age-related functional domains.

METHODS

We used data from ComprehenSIVe Evaluation of Risk in Older Adults with AMI (SILVER-AMI), a prospective cohort study that enrolled participants aged ≥75 years with AMI from 94 US hospitals. Participants underwent an in-hospital assessment of functional impairments, including cognition, vision, hearing and mobility. Clinical variables previously shown to be associated with readmission risk were also evaluated. The outcome was 180-day readmission. From an initial list of 72 variables, we used backward selection and Bayesian model averaging to derive a risk model (N=2004) that was subsequently internally validated (N=1002).

RESULTS

Of the 3006 SILVER-AMI participants discharged alive, mean age was 81.5 years, 44.4% were women and 10.5% were non-white. Within 180 days, 1222 participants (40.7%) were readmitted. The final risk model included 10 variables: history of chronic obstructive pulmonary disease, history of heart failure, initial heart rate, first diastolic blood pressure, ischaemic ECG changes, initial haemoglobin, ejection fraction, length of stay, self-reported health status and functional mobility. Model discrimination was moderate (0.68 derivation cohort, 0.65 validation cohort), with good calibration. The predicted readmission rate (derivation cohort) was 23.0% in the lowest quintile and 65.4% in the highest quintile.

CONCLUSIONS

Over 40% of participants in our sample experienced hospital readmission within 180 days of AMI. Our final readmission risk model included a broad range of characteristics, including functional mobility and self-reported health status, neither of which have been previously considered in 180-day risk models.

A Predictive Model of Intrinsic Factors Associated with Long-Stay Nursing Home Care After Hospitalization

We aimed to build a predictive model with intrinsic factors measured upon admission to skilled nursing facilities (SNFs) post-acute care (PAC) to identify older adults transferred from SNFs to long-term care (LTC) instead of home. We analyzed data from Massachusetts in 23,662 persons admitted to SNFs from PAC in 2013. Explanatory logistic regression analysis identified single "intrinsic predictors" related to LTC placement. To assess overfitting, the logistic regression predictive model was cross-validated and evaluated by its receiver operating characteristic (ROC) curve. A 12-variable predictive model with "intrinsic predictors" demonstrated both high in-sample and out-of-sample predictive accuracy in the receiver operating characteristic ROC and area under the ROC among patients at risk of LTC placement. This predictive model may be used for early identification of patients at risk for LTC after hospitalization in order to support targeted rehabilitative approaches and resource planning.

Expectations and experiences with physician care among patients receiving post-acute care in US skilled nursing facilities

BACKGROUND

In the US, post-acute care in skilled nursing facilities (SNFs) is common and outcomes vary greatly across facilities. Little is known about the expectations of patients and their caregivers about physician care during the hospital to SNF transition. Our objectives were to (1) describe the experiences and expectations of patients and their caregivers with SNF physicians in SNFs, and (2) identify patterns that differed between patients with vs. without cognitive impairment.

METHODS

This qualitative study used grounded theory approach to analyze data collected from semi-structured interviews at five SNFs in January-August 2018. Patients admitted for short-term SNF care 5-10 days prior were eligible to participate. Thematic analysis was performed to detect recurrent themes with a focus on modifiable aspects of physician care. Analysis was stratified by patient cognitive impairment (measured by the Montreal Cognitive Assessment at the time of the interview).

RESULTS

Fifty patients and six caregivers were interviewed. Major themes were: (1) patients had poor awareness of the physician in charge of their care; (2) they were dissatisfied with the frequency of interaction with the physician; and (3) participants valued the perception of receiving individualized care from the physician. Less cognitively impaired patients were more concerned about limited interactions with the physicians and were more likely to report attempts to seek out the physician.

CONCLUSION

Patient and caregiver expectations of SNF physicians were not well aligned with their experiences. SNFs aiming to improve satisfaction with care may focus efforts in this area, such as facilitating frequent communication between physicians, patients and caregivers.

Free-Text Documentation of Dementia Symptoms in Home Healthcare: A Natural Language Processing Study

Background

Little is known about symptom documentation related to Alzheimer's disease and related dementias (ADRD) by home healthcare (HHC) clinicians.

Objective

This study: (1) developed a natural language processing (NLP) algorithm that identifies common neuropsychiatric symptoms of ADRD in HHC free-text clinical notes; (2) described symptom clusters and hospitalization or emergency department (ED) visit rates for patients with and without these symptoms.

Method

We examined a corpus of -2.6 million free-text notes for 112,237 HHC episodes among 89,459 patients admitted to a non-profit HHC agency for post-acute care with any diagnosis. We used NLP software (NimbleMiner) to construct indicators of six neuropsychiatric symptoms. Structured HHC assessment data were used to identify known ADRD diagnoses and construct measures of hospitalization/ED use during HHC.

Results

Neuropsychiatric symptoms were documented for 40% of episodes. Common clusters included impaired memory, anxiety and/or depressed mood. One in three episodes without an ADRD diagnosis had documented symptoms. Hospitalization/ED rates increased with one or more symptoms present.

Conclusion

HHC providers should examine episodes with neuropsychiatric symptoms but no ADRD diagnoses to determine whether ADRD diagnosis was missed or to recommend ADRD evaluation. NLP-generated symptom indicators can help to identify high-risk patients for targeted interventions.

Dementia screening in elderly high-risk patients following heart failure decompensation may predict unfavorable long-term clinical outcomes

BACKGROUND

Recently heart failure (HF) has been found to be a new dementia risk factor; nevertheless, their relations in patients following HF decompensation remain unknown. We sought to investigate whether a screening diagnosis for dementia (SDD) in this high-risk population may predict unfavorable long-term clinical outcomes.

METHODS

One hundred forty-two patients following HF decompensation requiring hospitalization were enrolled. Within a median time of 55 months all patients were screened for dementia with ALFI-MMSE scale whereas their compliance was assessed with the Morisky Medication Adherence Scale. Any incidents of myocardial infarction, coronary revascularization, stroke or transient ischemic attack (TIA), revascularization, HF hospitalization and bleedings during follow-up were collected.

RESULTS

SDD was established in 37 patients (26%) based on the result of an ALFI-MMSE score of <17 points. By multivariate analysis the lower results of the ALFI-MMSE score were associated with a history of stroke/TIA (β=-0.29, P<0.001), peripheral arterial disease (PAD) (β=-0.20, P=0.011) and lower glomerular filtration rate (β=0.24, P=0.009). During the follow-up, patients with SDD were more often rehospitalized following HF decompensation (48.7% vs. 28.6%, P=0.042) than patients without SDD, despite a similar level of compliance (P=0.25). Irrespective of stroke/TIA history, SDD independently increased the risk of rehospitalization due to HF decompensation (HR 2.22, 95% CI: 1.23-4.01, P=0.007).

CONCLUSIONS

In patients following decompensated HF, a history of stroke/TIA, PAD and impaired renal function independently influenced SDD. In this high-risk population, SDD was not related with patients' compliance but irrespective of the stroke/TIA history it was associated with the increased risk of HF rehospitalization.

Implications of 2020 Skilled Home Healthcare Payment Reform for Persons with Dementia

BACKGROUND/OBJECTIVES

The Medicare home health benefit provides episodic skilled home-based clinical care to the growing population of community-dwelling persons with dementia. As of January 1, 2020, home health payment changed: episodes shortened from 60 to 30 days, and episodes initiated in the community are now reimbursed at lower rates than episodes following institutional stays. We aim to assess the potential impact of these policy changes on this population.

DESIGN/SETTING

Cross-sectional study using the Medicare claims-linked National Health and Aging Trends Study (NHATS).

PARTICIPANTS

A total of 1,867 NHATS respondents who received home health between 2011 and 2017.

MEASUREMENTS

Dementia was defined through both self-report and a validated cognitive assessment through NHATS. We described the demographic, socioeconomic, and health characteristics of older adults with dementia receiving home health compared with those without dementia. We then assessed the association of dementia with both receiving community-initiated home health (vs postinstitutional) and visit timing during the home health episode.

RESULTS

Over a follow-up period of just over 4 years, 50.2% of persons with dementia used home health compared with 15.3% of persons without dementia. Most home health provided to persons with dementia was initiated in the community (61%), compared with 37% of episodes provided to persons without dementia. Persons with dementia were more likely to receive care in days 31 to 60 of the episode compared with those without dementia.

CONCLUSIONS

Shortening episodes and reimbursing community-initiated episodes at lower rates may disproportionately impact the highly vulnerable population of older adults with dementia, who receive more community-initiated care over longer time periods. Our work highlights the need to better understand the unique role of home health in meeting gaps in both acute- and long-term care systems for older adults with dementia. J Am Geriatr Soc 68:2303-2309, 2020.

Function and Caregiver Support Associated With Readmissions During Home Health for Individuals With Dementia

OBJECTIVE

The purpose of this study was to determine the association between mobility, self-care, cognition, and caregiver support and 30-day potentially preventable readmissions (PPR) for individuals with dementia.

DESIGN

This retrospective study derived data from 100% national Centers for Medicare and Medicaid Services data files from July 1, 2013, through June 1, 2015.

PARTICIPANTS

Criteria from the Home Health Claims-Based Rehospitalization Measure and the Potentially Preventable 30-Day Post Discharge Readmission Measure for the Home Health Quality Reporting Program were used to identify a cohort of 118,171 Medicare beneficiaries.

MAIN OUTCOME MEASURE

The 30-day PPR rates with associated 95% CIs were calculated for each patient characteristic. Multilevel logistic regression was used to study the relationship between mobility, self-care, caregiver support, and cognition domains and 30-day PPR during home health, adjusting for patient demographics and clinical characteristics.

RESULTS

The overall rate of 30-day PPR was 7.6%. In the fully adjusted models, patients who were most dependent in mobility (odds ratio [OR], 1.59; 95% CI, 1.47-1.71) and self-care (OR, 1.73; 95% CI, 1.61-1.87) had higher odds for 30-day PPR. Patients with unmet caregiving needs had 1.11 (95% CI, 1.05-1.17) higher odds for 30-day PPR than patients whose caregiving needs were met. Patients with cognitive impairment had 1.23 (95% CI, 1.16-1.30) higher odds of readmission than those with minimal to no cognitive impairment.

CONCLUSIONS

Decreased independence in mobility and self-care tasks, unmet caregiver needs, and impaired cognitive processing at admission to home health are associated with risk of 30-day PPR during home health for individuals with dementia. Our findings indicate that deficits in mobility and self-care tasks have the greatest effect on the risk for PPR.

Dementia Severity Associated With Increased Risk of Potentially Preventable Readmissions During Home Health Care

OBJECTIVES

Approximately 14% of Medicare beneficiaries are readmitted to a hospital within 30 days of home health care admission. Individuals with dementia account for 30% of all home health care admissions and are at high risk for readmission. Our primary objective was to determine the association between dementia severity at admission to home health care and 30-day potentially preventable readmissions (PPR) during home health care. A secondary objective was to develop a dementia severity scale from Outcome and Assessment Information Set (OASIS) items based on the Functional Assessment Staging Tool (FAST).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Home health care; 126,292 Medicare beneficiaries receiving home health care (July 1, 2013-June 1, 2015) diagnosed with dementia (ICD-9 codes).

MEASURES

30-day PPR during home health care. Dementia severity categorized into 6 levels (nonaffected to severe).

RESULTS

The overall rate of 30-day PPR was 7.6% [95% confidence interval (CI) 7.4, 7.7] but varied by patient and health care utilization characteristics. After adjusting for sociodemographic and clinical characteristics, the odds ratio (OR) for dementia severity category 6 was 1.37 (95% CI 1.29, 1.46) and the OR for category 7 was 1.94 (95% CI 1.64, 2.31) as compared to dementia severity category 1/2.

CONCLUSIONS AND IMPLICATIONS

Dementia severity in the later stages is associated with increased risk for potentially preventable readmissions. Our findings suggest that individuals admitted to home health during the later stages of Alzheimer's disease and related dementias may require greater supports and specialized care to minimize negative outcomes such as readmissions. Development of a dementia severity scale based on OASIS items and the FAST is feasible. Future research is needed to determine effective strategies for decreasing potentially preventable readmissions of individuals with severe dementia who receive home health care. Future research is also needed to validate the proposed dementia severity categories used in this study.

Hospital readmission in persons with dementia: A systematic review

OBJECTIVE

Hospital readmission in persons with dementia is becoming a critical safety and cost issue. The purpose of this review is to systematically assess published evidence on hospital readmissions in persons with dementia, including rate, clinical reasons, risk factors, and prevention programs.

METHODS

A systematic review of relevant literature was conducted. Literature were searched in PubMed, CINAHL, PsycINFO, and Embase as well as hand searching. Quality of reviewed studies were assessed independently by reviewers using quality assessment checklists.

RESULTS

Nineteen studies met the inclusion criteria and were reviewed. In persons with dementia, all-cause 30-day readmission rate was most frequently reported and ranged from 7% to 35%. Compared with those without dementia, persons with dementia had significantly higher rate of readmission. Reported risk factors of readmission varied across studies from patient sociodemographic and clinical status, history of health care utilization, to family caregivers. Reasons for readmission were rarely documented. Programs of home-based individualized care and interdisciplinary team care were used for preventing readmissions. Findings from some of the studies were limited by small sample sizes, single data source, and other methodologic flaws.

CONCLUSIONS

Persons with dementia are at high risk for hospital readmission, but many of the readmissions are potentially preventable. Multiple strategies such like identifying high-risk individuals and the clinical reasons for index admission and readmission and implementing home-based individualized care by interdisciplinary team can reduce preventable hospital readmissions. Future studies should use multiple national data sources and advanced methodology to identify risk factors and clinical reasons of hospital readmissions.

The association of cognitive impairment as screened by the Mini-Cog with long term post-hospitalization outcomes

BACKGROUND

Prior studies have suggested that patients with cognitive impairment are at increased risk for adverse post-hospitalization outcomes. We aimed to determine if cognitive status assessed by the Mini-Cog, a quick bedside screening test, is associated with long-term outcomes.

METHODS

In this secondary analysis of data from a prospective cohort study, 668 patients >65 years of age admitted to a tertiary care academic hospital over a two-year period were screened for cognitive impairment with the Mini-Cog within 24 h of admission. We performed multivariable regression adjusting for demographics, comorbidities, principal diagnoses and functional status to determine association between cognitive impairment and discharge to post-acute care, 90-day readmission and one-year mortality.

RESULTS

Overall 35% screened positive for cognitive impairment. Those with impairment were older (median age 83 versus 78), less likely to be admitted from home and had lower functional independence and self-reported performance scores (p < 0.001 for all). Patients with cognitive impairment were more likely to be discharged to post-acute care facilities (54% versus 39%, p < 0.001). 90-day readmission rate of patients with and without cognitive impairment was 35% versus 27%; one-year survival 77% versus 84% and median length-of-stay was 4 days for both groups. Differences in readmission and mortality were not statistically significant after adjusting for covariates.

CONCLUSION

Cognitive impairment as screened for by the Mini-Cog was not associated with readmission, length-of-stay, or 1-year mortality but was associated with discharge to post-acute care. Other tools such as frailty assessment may be more useful in predicting these outcomes in hospitalized older adults.

The Impact of Hospitalization on Readmission, Institutionalization, and Mortality of People with Dementia: A Systematic Review and Meta-Analysis

BACKGROUND

People with dementia (PwD) are at a high risk of hospitalization. Hospitals are often not adequately equipped for PwD and discharges often come unexpected. Therefore, PwD are at a risk of adverse outcomes. However, information about those outcomes is rare but crucial for the development of preventive strategies.

OBJECTIVES

To conduct a quantitative systematic review and meta-analyses on the impact of a hospitalization on readmission, institutionalization, and mortality in PwD. To identify factors associated with these outcomes.

METHODS

PubMed, CENTRAL, and ScienceDirect were searched for studies including terms for dementia, hospital, readmission, institutionalization, and mortality. Relevant were assessed by a quality criteria sheet. Results were summarized in a table. Meta-analysis was conducted with Review Manager 5.3.

RESULTS

The search yielded 1,108 studies; 20 fulfilled the inclusion criteria and 10 studies were eligible for meta-analyses. The incidence and relative risk (RR) of mortality (RR 1.74 CI95 % 1.50, 2.05) and institutionalization (RR: 2.16 CI95 % 1.31, 3.56) of PwD was significantly higher when compared to people without dementia. Results according to readmission rate were inconsistent. Factors significantly associated with the examined adverse outcomes were severity of dementia, number of medications, and deficits in daily living activities.

CONCLUSION

Hospitalization of PwD lead to adverse outcomes. An improvement in the identification of and care for PwD in the acute setting as well as in after care in the community setting, especially in the interface between both settings, is required to prevent adverse outcomes in hospitalized PwD.

Predictors of readmission and long length of stay in elders admitted with neurological disorders in a tertiary center: a real-world investigation

ABSTRACT Hospital readmission and long length of stay (LOS) increase morbidity and hospital mortality and are associated with excessive costs to health systems. Objective: This study aimed to identify predictors of hospital readmission and long LOS among elders with neurological disorders (NDs). Methods: Patients ≥ 60 years of age admitted to the hospital between January 1, 2009, and December 31, 2010, with acute NDs, chronic NDs as underpinnings of acute clinical disorders, and neurological complications of other diseases were studied. We analyzed demographic factors, NDs, and comorbidities as independent predictors of readmission and long LOS (≥ 9 days). Logistic regression was performed for multivariate analysis. Results: Overall, 1,154 NDs and 2,679 comorbidities were identified among 798 inpatients aged ≥ 60 years (mean 75.8 ± 9.1). Of the patients, 54.5% were female. Patient readmissions were 251(31%) and 409 patients (51%) had an LOS ≥ 9 days (95% confidence interval 48%–55%). We found no predictors for readmission. Low socioeconomic class (p = 0.001), respiratory disorder (p < 0.001), infection (p < 0.001), genitourinary disorder (p < 0.033), and arterial hypertension (p = 0.002) were predictors of long LOS. Identified risks of long LOS explained 22% of predictors. Conclusions: Identifying risk factors for patient readmission are challenges for neurology teams and health system stakeholders. As low socioeconomic class and four comorbidities, but no NDs, were identified as predictors for long LOS, we recommend studying patient multimorbidity as well as functional and cognitive scores to determine whether they improve the risk model of long LOS in this population.

CE: Original Research: New Acute Symptoms in Older Adults with Cognitive Impairment: What Should Family Caregivers Do?

: Background: When older adults with cognitive impairment develop new physical or behavioral symptoms, their family caregivers face a difficult decision: whether and when to seek professional medical care. Most family caregivers lack formal training in assessment and may have difficulty making such decisions. The Veterans Health Administration's home-based primary care (HBPC) program, which is widely available, offers community-dwelling frail veterans and their family caregivers guidance, with the goal of reducing hospitalization and institutionalization in long-term care facilities.

OBJECTIVE

This study sought to assess the frequency with which family caregivers of cognitively impaired older adults sought prehospital guidance from health care professionals when that resource was available to them, and to describe the characteristics of such events.

METHODS

This study used a retrospective chart review of patients who were enrolled in the Orlando Veterans Affairs Medical Center HBPC program for at least one month between October 1, 2013, and September 30, 2014; had a diagnosis indicative of cognitive impairment (Alzheimer's disease, vascular dementia, or mild cognitive impairment); had a dedicated family caregiver; and were not enrolled in hospice care. Data were collected from data collection templates and nurses' narrative notes. Univariate descriptive analyses were conducted regarding the type of staff contacted by family caregivers, the presenting diagnoses, the guidance offered by staff, and the number of unplanned acute care encounters.

RESULTS

Among the 215 patients studied, there were 254 unplanned acute care encounters (including ED visits followed by discharge to home and ED visits resulting in hospital admission). Family caregivers sought guidance from a health care professional 22% of the time before such an encounter. The presenting clinical issues were most often new problems (43%) that included falls, feeding tube problems, fever, new pain, rash or other skin problems, and unexplained edema. Overall, 25% of all unplanned acute care encounters were for reasons considered potentially avoidable. About half of the patients who were subsequently hospitalized had symptoms of delirium, indicating that their illness had significantly advanced before presentation.

CONCLUSIONS

It's important for health care professionals to ensure that family caregivers of cognitively impaired older adults can access professional guidance readily when facing decisions about a loved one's care, especially when there is an acute onset of new symptoms. Teaching caregivers how to recognize such symptoms early in order to prevent exacerbations of chronic illness and subsequent hospitalization should be a high priority. Our findings underscore the need to do so, so that caregivers can best use the resources that HBPC programs have (or ought to have) in place, in particular 24/7 guidance and decision assistance.

Dementia in older people admitted to hospital: An analysis of length of stay and associated costs

OBJECTIVES

Patients with dementia in the acute setting are generally considered to impose higher costs on the health system compared to those without the disease largely due to longer length of stay (LOS). Many studies exploring the economic impact of the disease extrapolate estimates based on the costs of patients diagnosed using routinely collected hospital discharge data only. However, much dementia is undiagnosed, and therefore in limiting the analysis to this cohort, we believe that LOS and the associated costs of dementia may be overestimated. We examined LOS and associated costs in a cohort of patients specifically screened for dementia in the hospital setting.

METHODS

Using primary data collected from a prospective observational study of patients aged ≥70 years, we conducted a comparative analysis of LOS and associated hospital costs for patients with and without a diagnosis of dementia.

RESULTS

There was no significant difference in overall length of stay and total costs between those with (μ = 9.9 days, μ = € 8246) and without (μ = 8.25 days, μ = € 6855) dementia. Categorical data analysis of LOS and costs between the two groups provided mixed results.

CONCLUSIONS

The results challenge the basis for estimating the costs of dementia in the acute setting using LOS data from only those patients with a formal dementia diagnosis identified by routinely collected hospital discharge data. Accurate disease prevalence data, encompassing all stages of disease severity, are required to enable an estimation of the true costs of dementia in the acute setting based on LOS.

Association Between Patient Cognitive and Functional Status and Medicare Total Annual Cost of Care: Implications for Value-Based Payment

IMPORTANCE

Medicare is moving toward value-based payment. The Merit-Based Incentive Payment System (MIPS) program judges outpatient clinicians' performance on a measure of annual Medicare spending. However, this measure may disadvantage outpatient clinicians who care for vulnerable populations because the algorithm omits meaningful determinants of cost.

OBJECTIVES

To determine whether factors not included in Medicare risk adjustment, including patient neuropsychological and functional status, as well as local area health resources and economic conditions, are associated with Medicare total annual cost of care (TACC), and evaluate whether accounting for these factors is associated with improved TACC performance by outpatient safety-net clinicians.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective observational study, we used the Medicare Current Beneficiary Survey (MCBS) to examine patient-reported neuropsychological and functional status and the Area Health Resources File to obtain information on local area characteristics. Included were Medicare beneficiaries with annual physician or clinic visits to outpatient safety-net (federally qualified health centers and rural health clinics) and non-safety-net clinics, contributing 76 927 person-years of data to the MCBS from 2006 through 2013. We used patient-level multivariable regression models to estimate the association between each factor and annual Medicare spending, and compared outpatient safety-net performance under current risk adjustment and after adding additional adjustment for these factors.

MAIN OUTCOMES AND MEASURES

Medicare TACC, measured as the total annual reimbursed amount per patient for Medicare Part A and Part B services, in all categories.

RESULTS

Our study included 111 414 unique identifiable physicians, and the final weighted sample included 213 904 324 patient-years (unweighted, 76 927 patient-years) from 30 058 unique patients, of whom 17 478 (58.1%) were women. The mean (SD) patient age was 71.84 (12.48) years. The mean TACC was $9117. Those with higher than mean TACC included beneficiaries with depression ($14 436), dementia ($18 311), and difficulty with 3 or more activities of daily living (ADLs, $19 113) or instrumental ADLs ($17 443). After adjusting for comorbidities, depression and dementia were still associated with $2740 (95% CI, $2200-$2739) and $2922 (95% CI, $2399-$3445) higher TACC, respectively. Difficulty with 3 or more ADLs ($3121 higher; 95% CI, $2633-$3609) or instrumental ADLs ($895 higher; 95% CI, $452-$1337) was also associated with higher TACC. Adding these neuropsychological and functional factors, as well as local residence area factors, to risk adjustment calculations reduced outpatient safety-net clinicians' underperformance on Medicare TACC relative to non-safety-net clinicians by 52% (from 0.098 to 0.047 difference in the observed to expected ratio).

CONCLUSIONS AND RELEVANCE

Neuropsychological and functional impairment are common in Medicare beneficiaries and are associated with increased annual Medicare spending. Failure to account for these factors may inappropriately penalize outpatient clinicians who care for these vulnerable groups, such as safety-net clinicians, for factors that are arguably beyond their control.

90-Day Hospital Readmissions of Patients in a Geriatric Acute Care Ward in Singapore

The objective of the study is to examine the 90-day readmission rate and identify the predictors for 90-day readmissions at a geriatric ward in a tertiary hospital in Singapore. A secondary analysis of case-control data was performed. Data of patients discharged from a geriatric ward between January 2015 and January 2016 were retrieved from an existing data set. Out of 564 index admissions involving older adults, the 90-day geriatric readmission rate was 10.1%. Activities of daily living dependency (odds ratio [OR]: 0.988, 95% confidence interval [CI]: [0.978, 0.999]) and living with the spouse (OR: 2.988, 95% CI: [1.388, 6.432]) were identified as significant predictors of 90-day geriatric readmissions. The study suggests that rehabilitation to restore the geriatric patient's ability to perform daily activities and adequate caregiver training for the spouse are essential in reducing geriatric readmissions. Also, postdischarge follow-up with both the patient and caregiver can greatly reduce the risk of readmission in geriatric patients.

Reducing disability via a family centered intervention for acutely ill persons with Alzheimer's disease and related dementias: protocol of a cluster-randomized controlled trial (Fam-FFC study)

Background

Hospitalized older persons with Alzheimer’s disease and related dementias are at greater risk for functional decline and increased care dependency after discharge due to a combination of intrinsic factors, environmental, policy, and care practices that restrict physical and cognitive activity, lack of family involvement and limited staff knowledge of dementia care. We have developed a theory-based intervention, Family centered Function-focused Care, that incorporates an educational empowerment model for family caregivers (FCGs) provided within a social-ecological framework to promote specialized care to patients with dementia during hospitalization and the 60-day post-acute period. Primary aims are to test the efficacy of the intervention in improving physical and cognitive recovery in hospitalized persons living with Alzheimer’s disease and related dementias (ADRD) and improving FCG preparedness and experiences.

Method

We will implement Family centered Function-focused Care in a cluster-randomized trial of 438 patient/FCG dyads in six hospital units randomized within three hospitals. We hypothesize that patients who receive the intervention will demonstrate better physical function, less delirium occurrence and severity, neuropsychiatric symptoms, and depression compared to those in the control condition (Education-only). We also hypothesize that FCGs enrolled in Family centered Function-focused Care will experience increased preparedness for caregiving, and less strain, burden, and desire to institutionalize, as compared to FCGs the control group. We will also examine the costs and relative cost savings associated with the intervention and will evaluate the cultural appropriateness of Family centered Function-focused Care for families from diverse backgrounds.

Discussion

Our theory-based intervention makes use of real-world applicable approaches in a novel and innovative way to change the paradigm of how we currently look at acute care and post-acute transitions in persons with ADRD.

Trial registration

ClinicalTrials.gov, ID: NCT03046121. Registered on 8 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2875-1) contains supplementary material, which is available to authorized users.

Hospital admissions 2000-2014: A retrospective analysis of 288 096 events in patients with dementia

INTRODUCTION

Dementia is a leading cause of disability worldwide. It is associated with an increased risk of hospitalization, imposing a significant burden on healthcare systems. The evidence on the long-term evolution of this issue and broadly on healthcare systems is currently limited. This study aims to describe the hospitalizations of people who received a diagnosis of dementia admitted to public general hospitals in a western European country with universal health coverage, over more than a decade.

METHODS

This retrospective observational study analyzed all inpatient episodes from 2000 to 2014 with a primary or secondary diagnosis of dementia using a national hospitalization database from mainland Portuguese public hospitals.

RESULTS

A total of 288 096 hospital admissions were registered. Hospitalization rates increased 4.7 times throughout the study period. Pneumonia and urinary tract infections were the most frequent main diagnoses, while dementia itself was the cause of admission in a minority (6.8%) of cases. Cerebrovascular disease, diabetes without chronic complications, and congestive heart failure were the most prevalent comorbidities; 5.9% of patients with dementia admitted to hospital underwent a surgical procedure, orthopedic surgeries being the most frequent. The median length of hospital stay was 8.0 days, and in-hospital mortality rate was 16.1%.

CONCLUSIONS

Dementia patients represent a significant amount of hospital admissions. Most leading causes of hospital admissions are preventable if timely diagnosed and could be effectively managed in the outpatient setting. These findings may be useful for healthcare resource planning and allocation. Further research should drive evidence-based reorganization of health care systems.

Determinants of hospitalization and length of stay among people with dementia - An analysis of statutory health insurance claims data

OBJECTIVE

Dementia is a crucial challenge in acute care hospitals. Using a retrospective claims data cohort, this paper explores dementia patients' acute hospitalization rates, risk factors, and length of stay.

METHODS

The study used claims data from AOK PLUS, the largest statutory health insurance service (SHI) in Saxony, a federal state of Germany. The analysis included 61,239 people with dementia and 183,477 control subjects, all 65 years and older. Control subjects were age, gender, and regionally matched in a 1:3 ratio. Negative binomial hurdle regression was used to compare differences in hospitalization for the year 2014.

RESULTS

People with dementia had 1.49 times higher adjusted odds of being hospitalized at least once (95% confidence interval [CI], 1.46-1.52). Among those individuals hospitalized at least once, dementia increased the number of readmissions by 18% (95% CI, 1.15-1.20). Dementia patients also had a 1.74 times higher odds for at least one emergency admission compared to individuals without dementia (95% CI, 1.70-1.78). Dementia patients' admission risk factors included having care dependency, being recently diagnosed with dementia and living outside a metropolitan region. The increased length of stay for people with dementia per year was mainly attributable to higher admission rates.

CONCLUSIONS

Dementia patients are at higher risk for hospitalization, especially if they live outside the metropolitan region. Healthcare systems need to respond to the challenges resulting from the predicted demographic developments and increasing burden of dementia in the general population.

Can a systems approach reduce adverse outcomes in patients with dementia in acute settings? (innovative practice)

People with dementia experience adverse outcomes such as pressure sores during their stay in acute hospitals. The application of a systems approach in an acute setting places an emphasis on the patient’s journey in addition to the organisational factors that are present within a hospital context. This article draws upon principles obtained from a theoretical model, which was extracted from the work of Edwards (1972), Hawkins (1987) and Zecevic et al. (2007), in order to illustrate how the application of a novel systems approach (human interaction, environment, equipment and policy) could be used in acute hospital settings to reduce adverse health outcomes by using an imaginary patient with dementia.

Dementia and Hospital Readmission Rates: A Systematic Review

Background

Although community-dwelling persons with dementia have an increased risk of hospital readmission, no systematic review has examined the contribution of dementia to readmissions.

Summary

We examined articles in English, with no restrictions on publication dates, from Medline, PubMed, PsycINFO, CINAHL, and EMBASE. Keywords used were dementia, Alzheimer disease, frontotemporal lobar degeneration, elderly, frontotemporal dementia, executive function, brain atrophy, frontal lobe atrophy, cognitive impairment, readmission, readmit, rehospitalization, patient discharge, and return visit. Of 404 abstracts identified, 77 articles were retrieved; 12 were included. Four of 5 cohort studies showed significantly increased readmission rates in patients with dementia. On average the absolute increase above the comparison groups was from 3 to 13%. Dementia was not associated with readmission in 7 included case-control studies.

Key Message

Findings suggest a small increased risk of hospital readmission in individuals with dementia. More study is needed.

Does admission to a specialist geriatric medicine ward lead to improvements in aspects of acute medical care for older patients with dementia?

OBJECTIVE

The objective of this study is to clarify if admission to a specialist geriatric medicine ward leads to improvements in aspects of acute medical care for patients with dementia.

METHODS

We analysed combined data involving 900 patients from the Irish and Northern Irish audits of dementia care. Data on baseline demographics, admission outcomes, clinical aspects of care, multidisciplinary assessment and discharge planning processes were collected.

RESULTS

Less than one-fifth of patients received their inpatient care on a specialist geriatric medicine ward. Patients admitted to a geriatric medicine ward were less likely to undergo a formal assessment of mobility compared with those in non-geriatric wards (119/143 (83%) vs 635/708 (90%), odds ratio (OR) = 0.57 (0.35 to 0.94)) and were more likely to receive newly prescribed antipsychotic medication during the admission (27/54 (50%) vs 95/2809 (36%), OR = 1.95 (1.08 to 3.51)). Patients admitted to a geriatric medicine ward were more likely to have certain aspects of discharge planning initiated, including completion of a single plan for discharge (78/118 (66%) vs 275/611 (45%), OR = 2.38 (1.58 to 3.60)). Surgical wards performed more poorly on certain aspects including having a named discharge co-ordinator (32/71, 45%) and documentation of decisions regarding resuscitation status (18/95, 19%).

CONCLUSION

Relatively low numbers of patients with dementia received care on a specialist geriatric medicine ward. There appears to be a more streamlined discharge planning process in place on these wards, but they did not perform as well as one would expect in certain areas, such as compliance with multidisciplinary assessment and antipsychotic prescribing. Copyright © 2016 John Wiley & Sons, Ltd.

Poorer outcomes and greater healthcare costs for hospitalised older people with dementia and delirium: a retrospective cohort study

OBJECTIVE

To compare healthcare utilisation outcomes among older hospitalised patients with and without cognitive impairment, and to compare the costs associated with these outcomes.

METHODS

Retrospective cohort study of administrative data from a large teaching hospital in Melbourne, Australia from 1 July 2006 to 30 June 2012. People with cognitive impairment were defined as having dementia or delirium coded during the admission. Outcome measures included length of stay, unplanned readmissions within 28 days and costs associated with these outcomes. Regression analysis was used to compare differences between those with and without cognitive impairment.

RESULTS

There were 93 300 hospital admissions included in the analysis. 6459 (6.9%) involved cognitively impaired patients. The adjusted median length of stay was significantly higher for the cognitively impaired group compared with the non-cognitively impaired group (7.4 days 6.7-10.0 vs 6.6 days, interquartile range 5.7-8.3; p < 0.001). There were no differences in odds of 28-day readmission. When only those discharged back to their usual residence were included in the analysis, the risk of 28-day readmission was significantly higher for those with cognitive impairment compared with those without. The cost of admissions involving patients with cognitive impairment was 51% higher than the cost of those without cognitive impairment.

CONCLUSIONS

Hospitalised people with cognitive impairment experience significantly greater length of stay and when discharged to their usual residence are more likely to be readmitted to hospital within 28 days compared with those without cognitive impairment. The costs associated with hospital episodes and 28-day readmissions are significantly higher for those with cognitive impairment. Copyright © 2016 John Wiley & Sons, Ltd.