The residential history file: studying nursing home residents' long-term care histories(*)

Effects of Nursing Home Changes in Antipsychotic Use on Outcomes among Residents with Dementia

OBJECTIVES

Little information exists on whether nationwide efforts to reduce antipsychotic use among nursing home (NH) residents with Alzheimer's disease and related dementias improved mortality and hospitalization outcomes for residents. Our objective was to examine the effect of NH decreases in antipsychotic use on outcomes for residents with Alzheimer's disease and related dementias.

DESIGN

Observational nationwide study that emulated a series of cluster randomized trials.

SETTING AND PARTICIPANTS

Long-stay NH residents with Alzheimer's disease and related dementias in US NHs.

METHODS

The study used data from Medicare claims to emulate cluster randomized trials in which NHs were assigned to either decrease or maintain/increase antipsychotic use. Outcome ascertainment for the first trial began on April 1, 2012 (ie, following the announcement of the National Partnership to Improve Dementia Care in NHs). The last day of follow-up was December 31, 2017. Outcomes measured included 12-month all-cause mortality, all-cause hospitalization, and hospitalization for stroke, myocardial infarction, fracture, and psychiatric conditions. Use of other psychotropic medications was also evaluated. Inverse-probability-of-treatment-weighted pooled Poisson regression models estimated covariate-adjusted risk ratios (RRs).

RESULTS

The adjusted risks of death (RR, 1.01; 95% CLs, 1.00, 1.01), all-cause hospitalization (RR, 1.00; 95% CLs, 1.00, 1.01), and hospitalization for specific causes were similar between resident-trials in NHs that decreased vs maintained/increased antipsychotic use. Use of antidepressants, anxiolytic/sedative-hypnotics, anticonvulsant/mood stabilizers, and antidementia medications was slightly higher among resident-trials in NHs that decreased antipsychotic use.

CONCLUSIONS AND IMPLICATIONS

Decreases in NH antipsychotic use do not appear to improve resident outcomes. Intensive initiatives focused predominantly on achieving a decrease in antipsychotic use may not be effective at improving mortality and hospitalization outcomes for residents with Alzheimer's disease and related dementias. These findings suggest the need for better strategies that incorporate safe and effective nonpharmacological or pharmacological alternatives for managing neuropsychiatric symptoms of dementia.

Risk of Hospitalization Among Assisted Living Residents Dually Enrolled in Medicare and Medicaid

OBJECTIVES

To examine how risk of hospitalization among assisted living (AL) residents differs by dual enrollment in Medicare and Medicaid and by the percent of dually enrolled individuals in an AL community.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We used Medicare data from 2008 to 2018 and a national directory of licensed AL communities to identify Medicare beneficiaries with a change in their ZIP+4 code suggesting a new residence in an AL.

METHODS

We estimated linear regression models of hospitalization onto interactions of residents' dual enrollment status and categories of the AL community's percentage of dually enrolled residents. In the models, we adjusted for person-level clinical and demographic characteristics, year-fixed effects, and fixed effects for the AL residents' prior ZIP code.

RESULTS

Among 620,542 Medicare beneficiaries who moved to an AL community, the 1-year risk of hospitalization was higher for dually enrolled residents compared with Medicare-only residents. In adjusted models, dually enrolled residents in high-dual AL communities (>50% dually enrolled) had an 7.4% higher risk of hospital admission compared with dually enrolled residents in low-dual AL communities. Medicare-only beneficiaries in high-dual AL communities had a 9.4% higher risk of hospitalization than Medicare-only beneficiaries in low-dual ALs.

CONCLUSIONS AND IMPLICATIONS

The proportion of residents in an AL community who were dually enrolled was associated with residents' risk of hospitalization, regardless of their dual enrollment status. Additional research is needed to understand whether differences observed in residents' risk of hospitalization are due to differences in the types of services provided, unmeasured resident acuity, or the quality of care delivered in these settings.

Differences in setting of initial dementia diagnosis among fee-for-service Medicare beneficiaries

BACKGROUND

Accurate and timely diagnosis of dementia is necessary to allow affected individuals to make informed decisions and access appropriate resources. When dementia goes undetected until a hospitalization or nursing home stay, this could reflect delayed diagnosis or misdiagnosis, and may reflect underlying disparities in healthcare access.

METHODS

In this retrospective cohort study, we used 2012-2020 Medicare claims and other administrative data to examine variation in setting of dementia diagnosis among fee-for-service Medicare beneficiaries with an initial claims-based dementia diagnosis in 2016. We used multinomial logistic regression to evaluate the association of person and geographic factors with diagnosis location, and Cox proportional hazards regression to examine 4-year survival relative to diagnosis location.

RESULTS

Among 754,204 Medicare beneficiaries newly diagnosed with dementia in 2016, 60.3% were diagnosed in the community, 17.2% in hospitals, and 22.5% in nursing homes. Adjusted 4-year survival rates were significantly lower among those diagnosed in hospitals [-16.1 percentage points (95% CI: -17.0, -15.1)] and nursing homes [-16.8 percentage points (95% CI: -17.7, -15.9)], compared to those diagnosed in the community. Community-diagnosed beneficiaries were more often female, younger, Asian or Pacific Islander, Native American or Alaskan Native, Hispanic, had fewer baseline hospitalizations and higher homecare use, and resided in wealthier ZIP codes. Rural beneficiaries were more likely to be diagnosed in hospitals.

CONCLUSIONS

Many older adults are diagnosed with dementia in a hospital or nursing home. These individuals have significantly lower survival than those diagnosed in the community, which may indicate diagnosis during an acute illness or care transition, or at a later disease stage, all of which are suboptimal. These results highlight the need for improved dementia screening in the general population, particularly for individuals in rural areas and communities with higher social deprivation.

Long-Term Trajectories of Postoperative Recovery in Younger and Older Veterans

Importance

Major surgery sometimes involves long recovery or even permanent institutionalization. Little is known about long-term trajectories of postoperative recovery, as surgical registries are limited to 30-day outcomes and care can occur across various institutions.

Objective

To characterize long-term postoperative recovery trajectories.

Design, Setting, and Participants

This retrospective cohort study used Veterans Affairs (VA) Surgical Quality Improvement Program data (2016 through 2019) linked to the Residential History File, combining data from the VA, Medicare/Medicaid, and other sources to capture most health care utilization by days. Patients were divided into younger (younger than 65 years) or older (65 years or older) subgroups, as Medicare eligibility is age dependent. Latent-class, group-based trajectory models were developed for each group. These data were analyzed from February 2023 through August 2024.

Exposure

Surgical care in VA hospitals.

Main Outcomes and Measures

Days elsewhere than home (DEH) were counted in 30-day periods for 275 days presurgery and 365 days postsurgery.

Results

A 5-trajectory solution was optimal and visually similar for both age groups (cases: 179 879 younger [mean age (SD) 51.2 (10.8) years; most were male [154 542 (83.0%)] and 198 803 older [mean (SD) age, 72.2 (6.0) years; 187 996 were male (97.6%)]). Most cases were in trajectories 1 and 2 (T1 and T2). T1 cases returned home within 30 days (younger, 74.0%; older, 54.2%), while T2 described delayed recovery within 30 to 60 days (younger, 21.6%; older, 35.5%). Trajectory 3 (T3) and trajectory 4 (T4) were similar for the first 30 days postsurgery, but subsequently separated with T3 representing protracted recovery of 6 months or longer (younger, 2.7%; older, 3.8%) and T4 indicating long-term loss of independence (younger, 1.3%; older, 5.2%). Few (trajectory 5) were chronically dependent, with 20 to 30 DEH per month before and after surgery (younger, 0.4%; older, 1.3%).

Conclusions and Relevance

In this study, trajectory models demonstrated clinically meaningful differences in postoperative recovery that should inform surgical decision-making. Registries should include longer-term outcomes to enable future research to distinguish patients prone to long-term loss of independence vs protracted, but meaningful recovery.

Discontinuation of Cholinesterase Inhibitors Following Initiation of Memantine and Admission to Long-Term Care Among Older Adults

Importance

Discontinuing cholinesterase inhibitors when initiating memantine in patients with dementia may be reasonable to reduce treatment burden, costs, and the risk of adverse drug events.

Objective

To assess the association of cholinesterase inhibitor discontinuation on long-term care institutionalization among older adults with dementia who initiate memantine.

Design, Setting, and Participants

This retrospective propensity score-matched cohort study used Medicare claims data from January 2014 to December 2019. Participants included fee-for-service Medicare beneficiaries with dementia. Data were analyzed from September 2021 to August 2024.

Exposures

Discontinuation vs continuation of cholinesterase inhibitor.

Main Outcomes and Measures

The primary outcome was 1-year long-term care institutionalization-free days. Secondary outcomes include all-cause death and adverse drug events over 1 year. We performed subgroup analyses based on age, sex, dementia type (Alzheimer disease vs other), frailty, and dementia severity (mild vs moderate or severe) based on claims-based algorithms. The primary outcome was analyzed using nonparametric restricted mean survival time analysis.

Results

Among 16 292 beneficiaries who initiated memantine, 1820 (11.2%) discontinued cholinesterase inhibitors. In the propensity score-matched cohort of 3612 beneficiaries, the mean (SD) age was 80.7 (6.7) years, 2261 (62.6%) were female, and 1989 (55.0%) had a diagnosis of Alzheimer disease. Over 1 year, long-term care institutionalization occurred in 51 of 1806 beneficiaries (2.8%) who discontinued cholinesterase inhibitors (3.4 per 100 person-years) and 62 of 1806 beneficiaries (3.4%) who continued (4.1 per 100 person-years). There was no statistically significant difference in the 1-year mean institutionalization-free days between discontinuation and continuation groups (360.6 [95% CI, 359.3 to 362.0] days vs 359.1 [95% CI, 357.5 to 360.6] days; mean difference, 1.5 [95% CI,-0.5 to 3.6] days). The mean difference in the long-term care institutionalization-free days did not differ by age category, sex, dementia type, frailty, or dementia stage. Individuals who discontinued had a lower rate of fall-related injury (0.9 vs 2.0 per 100 person-years; hazard ratio [HR], 0.47 [95% CI, 0.25 to 0.88]). There was no difference between the discontinuation and continuation groups in all-cause death (10.4 vs 11.6 per 100 person-years; HR, 0.89 [95% CI, 0.72 to 1.10]).

Conclusions and Relevance

In this study, discontinuing cholinesterase inhibitors upon memantine initiation was not associated with an increased risk of long-term care institutionalization but with a lower risk of fall-related injury among older adults with dementia. These findings offer valuable insights for clinicians aiming to reduce treatment burden in this population.

Cholinesterase Inhibitor Initiation Does Not Increase the Risk of Fall-Related Injury in Older Adults Treated With Beta-Blockers: A Self-Controlled Case Series Design

BACKGROUND

Prescribing cholinesterase inhibitors (ChEIs) concurrently with beta-blockers might cause syncope that increases the risk of fall-related injuries (FRIs). This self-controlled case series study assesses the risk of FRIs associated with initiating ChEIs while receiving beta-blockers among Medicare fee-for-service-insured nursing home (NH) residents in the United States.

METHODS

We identified individuals at their first dispensing of a beta-blocker between 2016 and 2019 after at least 45 days of long-stay NH residency. Individuals were followed from the first day of beta-blocker use until beta-blocker discontinuation, Medicare disenrollment, death, or study end. ChEI initiation was classified as the first 60 days of new ChEI dispensing after 45 days of no ChEI exposure. FRIs were assessed during beta-blocker use periods, and age-adjusted incidence rate ratios (IRR) for ChEI-initiation days versus other days were calculated using conditional Poisson regression models. Analyses were weighted for event-dependent observation periods due to the high risk of mortality after an FRI in this population. Subgroup analyses were conducted for several key time-fixed variables, including sex, age, ChEI type, ChEI dose, beta-blocker selectivity, and beta-blocker dose.

RESULTS

The FRI risk after ChEI initiation was not elevated among 837 residents who experienced an FRI while using beta-blockers (IRR=0.90 [95%CLs 0.71, 1.15]). Analyses of ChEI initiation in several subgroups yielded similar results.

CONCLUSIONS

There was no substantial difference in FRI risk when initiating ChEIs among older NH residents receiving beta-blocker therapy versus periods without ChEI initiation, suggesting that there is no clinically significant pharmacodynamic drug-drug interaction between beta-blockers and ChEIs.

Provision of Home & Community Based Services to Veterans by Race, Rurality, and Neighborhood Deprivation Index

Home and community-based services (HCBS) enable frail patients to remain at home. We examined whether there were neighborhood-deprivation, racial, or rural disparities in HCBS utilization provided to Veterans by the Department of Veterans Affairs (VA) or Medicare by comparing the adjusted utilization rate of a historically disadvantaged group with the predicted utilization rate had it been treated as the historically dominant group. Among the 2.7 million VA patients over 66 years old in 2019, 11.0% were Black, 39.2% lived in rural settings, 15.3%/29.2%/30.9%/24.7% lived in least/mild/moderate/most-deprived neighborhoods. On average, 11.2% received VA or Medicare HCBS. Veterans residing in more deprived neighborhoods had 0.11-0.95% higher adjusted probability of receiving HCBS than expected had they resided in the least deprived neighborhoods. Veterans residing in rural areas had 0-0.7% lower HCBS rates than expected had they been treated like urban Veterans. Black Veterans were 0.8-1.2% more likely to receive HCBS than expected had they been treated like White Veterans. Findings indicate that VA resources were equitably employed, aligning with probable HCBS needs, suggesting that VA's substantial and long-standing investment in HCBS for care of frail Veterans could serve as a model for other payers and providers in the U.S.

Nationwide Availability of and Enrollment in Medicare and Medicaid Dual-Eligible Special Needs Plans With Exclusively Aligned Enrollment

Importance

In 2021, the Centers for Medicare & Medicaid Services designated a new category of dual-eligible special needs plans (D-SNPs) with exclusively aligned enrollment (receive Medicare and Medicaid benefits through the same plan or affiliated plans within the same organization).

Objective

To assess the availability of and enrollment in D-SNPs with exclusively aligned enrollment and to compare the characteristics of beneficiaries enrolled in D-SNPs with exclusively aligned enrollment available vs beneficiaries without such enrollment available.

Design, Setting, and Participants

Full-benefit beneficiaries enrolled in D-SNPs for 6 months or longer in 2021 or 2022. Availability of and beneficiary enrollment in D-SNPs were assessed by year and county for D-SNPs with exclusively aligned enrollment available vs D-SNPs without exclusively aligned enrollment available. The D-SNP enrollees residing in counties with aligned plans available were compared based on demographic, social, health, and area characteristics vs D-SNP enrollees in counties without such plans available. Comparisons were also made based on beneficiaries who enrolled in the aligned D-SNPs vs those who did not enroll (were enrolled in unaligned D-SNPs). The data analyses were conducted from October 1, 2023, to August 2, 2024.

Main Outcomes and Measures

Availability of aligned D-SNPs and beneficiary residence by county; enrollment in exclusively aligned D-SNPs vs unaligned D-SNPs; and beneficiary demographic, social, health, and area characteristics.

Results

Of 2 197 732 beneficiaries enrolled in D-SNPs in 2021, 881 736 (40.1%) were living in counties with aligned enrollment available and 251 305 (11.4%) enrolled. Of 2 689 045 beneficiaries enrolled in D-SNPs in 2022, 1 047 223 (38.9%) were living in counties with aligned enrollment available and 318 906 (11.9%) enrolled. Beneficiaries enrolled in D-SNPs residing in counties without aligned enrollment available were more likely to live in rural or micropolitan areas (21.9%) vs beneficiaries in counties with aligned enrollment available (8.1%) (standardized mean difference [SMD], 0.38 [95% CI, 0.38-0.38]), be entitled to disability (44.4% vs 27.3%, respectively; SMD, 0.36 [95% CI, 0.36-0.36]), or be Black individuals (27.4% vs 21.4%; SMD, 0.14 [95% CI, 0.14-0.14]); were less likely to be Hispanic individuals (15.4% vs 33.7%; SMD, 0.45 [95% CI, 0.45-0.45]) or Asian or Pacific Islander individuals (6.1% vs 12.2%; SMD, 0.22 [95% CI, 0.22-0.22]); and lived in zip codes with a higher area deprivation index (mean, 66.8 [SD, 26.4] vs mean, 43.2 [SD, 29.0]; SMD, 0.86 [95% CI, 0.86-0.86]). Beneficiaries enrolled in aligned D-SNPs were more likely to be receiving long-term institutionalized care vs beneficiaries in nonaligned D-SNPs (4.3% vs 1.0%, respectively; SMD, 0.24 [95% CI, 0.24-0.25]) or have dementia or Alzheimer disease (9.2% vs 5.9%; SMD, 0.13 [95% CI, 0.13-0.13]).

Conclusions

This study found that availability of and enrollment in D-SNPs with exclusively aligned enrollment are increasing, but the overall proportion enrolled remains low. Further reforms are needed to promote aligned enrollment.

Disparities in Access to Highly Rated Skilled Nursing Facilities among Medicare Beneficiaries with Opioid Use Disorder

OBJECTIVES

To investigate disparities in admissions to highly rated skilled nursing facilities (SNFs) between Medicare beneficiaries with and without opioid use disorder (OUD).

DESIGN

Nationwide, retrospective observational cohort.

SETTING AND PARTICIPANTS

Medicare Fee-for-Service beneficiaries aged ≥18 years admitted to SNFs following hospitalization during 2016-2020 (n = 30,922 with OUD and n = 137,454 without OUD).

METHODS

Data used were 100% Medicare inpatient claims, nursing home administrative databases, and Nursing Home Compare. We identified hospitalized patients with and without OUD and matched them on age, sex, Part D low-income subsidy (LIS), and residential county. We compared the overall and component (quality, staffing, and health inspections) star ratings of SNFs that beneficiaries entered. Beneficiary-level regression models were conducted adjusting for race and ethnicity, Medicare-Medicaid dual status, comorbidity score, hospital length of stay, and state and year fixed effects.

RESULTS

The overall study sample had a mean (SD) age of 71.4 (11.4) years, 63.9% were female, and 57.4% had LIS. Among beneficiaries with OUD, 50.3% entered SNFs with above-average (4 or 5) overall rating compared with 51.3% among those without OUD. Distributions of above-average ratings among beneficiaries with and without OUD were as follows: 63.9% vs 62.2% for quality, 32.8% vs 34.9% for health inspections, and 46.2% vs 45.0% for staffing, respectively. Adjusted regression models indicated that beneficiaries with OUD were less likely to be admitted to facilities with above-average overall (OR 0.90, 95% CI 0.87-0.92), health inspection (OR 0.90, 95% CI 0.88-0.93), and staffing (OR 0.91, 95% CI 0.89-0.94) ratings compared with beneficiaries without OUD, whereas quality (OR 0.98, 95% CI 0.95-1.01) ratings did not differ.

CONCLUSIONS AND IMPLICATIONS

Despite mixed results on component ratings, our findings suggest a concerning disparity in the overall quality of SNFs admitting Medicare beneficiaries with OUD. Enhancing equitable access to high-quality SNF care for individuals with OUD is imperative amid rising demand and legal protections under the American Disabilities Act.

Patterns of Migration Following Dementia Diagnosis

Importance

Diseases have historically prompted individual relocations to mitigate the risk of disease acquisition or improve access to care. As dementia prevalence increases, comprehending the migration patterns of affected individuals is vital for public policy.

Objective

To quantify the association of dementia diagnosis with migration patterns by examining the proportion of individuals with dementia who relocate, the timing of their moves relative to diagnosis, and the nature of their new living arrangements, whether in institutional settings or different households.

Design, Setting, and Participants

This cohort study leveraged a comprehensive dataset of national Medicare claims and assessments spanning from 2012 to 2020, including Medicare Beneficiary Summary File and nursing home administrative datasets. The study focused on beneficiaries who received diagnoses in 2016 of dementia, myocardial infarction, chronic obstructive pulmonary disease, or colon cancer. Analyses were performed from March 2023 to August 2024.

Main Outcomes and Measures

The primary outcome was migration, defined as change in county or state. The analysis distinguished between migrations with and without a nursing home stay. By tracking patients' residential county for 4 years before and after diagnosis, a difference-in-differences approach was used to contrast migration tendencies associated with dementia against the other 3 conditions.

Results

The sample included 1 626 127 Medicare beneficiaries (mean [SD] age, 80.1 [8.0] years; 922 194 women [56.7%]) who received diagnoses of the 4 conditions in 2016. In total, 818 862 had a new dementia diagnosis (age, 82.0 [7.8] years; 492 146 women [60.1%]). Comparing between the prediagnosis and postdiagnosis months, the proportion migrating to a different county increased by 8.5 percentage points (95% CI, 7.6-9.4 percentage points) for individuals with dementia and between 4.2 to 5.8 percentage points among those with myocardial infarction, chronic obstructive pulmonary disease, or colon cancer. The difference-in-difference estimates indicated a 3.9 percentage point (95% CI, 3.7-4.0 percentage points) increase in intercounty migration and a 1.9 percentage point (95% CI, 1.8-2.0 percentage points) increase in interstate migration for patients with dementia, effectively doubling the likelihood of migration compared with the other conditions. Of the excess migrations resulting from dementia diagnosis, 55% occurred in community settings, and 45% occurred in institutional settings.

Conclusions and Relevance

In this retrospective cohort study of Medicare fee-for-service beneficiaries, dementia was associated with a marked increase in migration rates over other major illnesses. This finding underscores the need to understand the factors associated with these distinct migration behaviors.

Nursing Home Characteristics Associated with Antipsychotic Prescribing After Implementation of the National Antipsychotic Reduction Initiative (ARI)

OBJECTIVES

To describe nursing home (NH) characteristics associated with antipsychotic use and test whether associations changed after implementation of the National Partnership to Improve Dementia Care's antipsychotic reduction initiative (ARI).

METHODS

Longitudinal quasi-experimental design using data from multiple sources and piecewise linear mixed models were used for statistical analyses.

RESULTS

There was a significant decrease in monthly antipsychotic use across the study period (pre-ARI b = -0.0003, p <.001; post-ARI b = -0.0012, p <.001), which held after adjusting for NH characteristics. Registered nurse hours (b = -0.0026, p <.001), licensed practical nurse hours (b = -0.0019, p <.001), facility chain membership (b = -0.0013, p <.01), and health inspection ratings (b = -0.0003, p >.01) were associated with decreased antipsychotic use. Post-ARI changes in associations between NH characteristics and antipsychotic use were small and not statistically significant.

CONCLUSIONS

Decreases in antipsychotic use were associated with most NH characteristics, and associations persisted post-ARI. Further research is warranted to examine the interactions between ARI policy and NH characteristics on antipsychotic prescribing, as well as other NH factors, such as facility prescribing cultures and clinical specialty of staff.

CLINICAL IMPLICATIONS

Decreases in monthly antipsychotic use were observed following the ARI. The decreases in monthly antipsychotic use were associated with most NH characteristics, and these associations persisted during the post-ARI period.

Prescribing Trends and Associated Outcomes of Antiepileptic Drugs and Other Psychotropic Medications in US Nursing Homes: Proposal for a Mixed Methods Investigation

BACKGROUND

Pilot data suggest that off-label, unmonitored antiepileptic drug prescribing for behavioral and psychological symptoms of dementia is increasing, replacing other psychotropic medications targeted by purposeful reduction efforts. This trend accelerated during the COVID-19 pandemic. Although adverse outcomes related to this trend remain unknown, preliminary results hint that harms may be increasing and concentrated in vulnerable populations.

OBJECTIVE

Using a mixed methods approach including both a retrospective secondary data analysis and a national clinician survey, this study aims to describe appropriate and potentially inappropriate antiepileptic and other psychoactive drug prescribing in US nursing homes (NHs), characteristics and patient-oriented outcomes associated with this prescribing, and how these phenomena may be changing under the combined stressors of the COVID-19 pandemic and the pressure of reduction initiatives.

METHODS

To accomplish the objective, resident-level, mixed-effects regression models and interrupted time-series analyses will draw on cohort elements linked at an individual level from the Centers for Medicare and Medicaid Services' (CMS) Minimum Data Set, Medicare Part D, Medicare Provider Analysis and Review, and Outpatient and Public Use Files. Quarterly cohorts of NH residents (2009-2021) will incorporate individual-level data, including demographics; health status; disease variables; psychotropic medication claims; comprehensive NH health outcomes; hospital and emergency department adverse events; and NH details, including staffing resources and COVID-19 statistics. To help explain and validate findings, we will conduct a national qualitative survey of NH prescribers regarding their knowledge and beliefs surrounding changing approaches to dementia care and associated outcomes.

RESULTS

Funding was obtained in September 2022. Institutional review board exemption approval was obtained in January 2023. The CMS Data Use Agreement was submitted in May 2023 and signed in March 2024. Data access was obtained in June 2024. Cohort creation is anticipated by January 2025, with crosswalks finalized by July 2025. The first survey was fielded in October 2023 and published in July 2024. The second survey was fielded in March 2024. The results are in review as of July 2024. Iterative survey cycles will continue biannually until December 2026. Multidisciplinary dissemination of survey analysis results began in July 2023, and dissemination of secondary data findings is anticipated to begin January 2025. These processes are ongoing, with investigation to wrap up by June 2027.

CONCLUSIONS

This study will detail appropriate and inappropriate antiepileptic drug use and related outcomes in NHs and describe disparities in long-stay subpopulations treated or not treated with psychotropics. It will delineate the impact of the pandemic in combination with national policies on dementia management and outcomes. We believe this mixed methods approach, including processes that link multiple CMS data sets at an individual level and survey-relevant stakeholders, can be replicated and applied to evaluate a variety of patient-oriented questions in diverse clinical populations.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64446.

Healthy Days at Home Among Older Medicare Beneficiaries With Traumatic Brain Injury Requiring Inpatient Rehabilitation

OBJECTIVE

The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation.

SETTING

Inpatient hospital, nursing home, and home health services.

PARTICIPANTS

Average of n = 631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72 hours of hospital discharge.

DESIGN

Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank.

MAIN MEASURES

The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge.

RESULTS

We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3 months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score ( β  = 0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score ( β  = - 0.06; 95% CI, -0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors ( β  = - 0.37; 95% CI, -0.66 to -0.07).

CONCLUSION

In this study, among community-dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs.

Initial and Long-Term Prescribing of Opioids and Non-steroidal Anti-inflammatory Drugs Following Total Hip and Knee Arthroplasty

Introduction

Limited evidence exists on health system characteristics associated with initial and long-term prescribing of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) following total hip and knee arthroplasty (THA/TKA), and if these characteristics differ among individuals based on preoperative NSAID exposure. We identified orthopedic surgeon opioid prescribing practices, hospital characteristics, and regional factors associated with initial and long-term prescribing of opioids and NSAIDs among older adults receiving THA/TKA.

Materials and Methods

This observational study included opioid-naïve Medicare beneficiaries aged ≥65 years receiving elective THA/TKA between January 1, 2014 and July 4, 2017. We examined initial (days 1-30 following THA/TKA) and long-term (days 90-180) opioid or NSAID prescribing, stratified by preoperative NSAID exposure. Risk ratios (RRs) for the associations between 10 health system characteristics and case-mix adjusted outcomes were estimated using multivariable Poisson regression models.

Results

The study population included 23,351 NSAID-naïve and 10,127 NSAID-prevalent individuals. Increases in standardized measures of orthopedic surgeon opioid prescribing generally decreased the risk of initial NSAID prescribing but increased the risk of long-term opioid prescribing. For example, among NSAID-naïve individuals, the RRs (95% confidence intervals [CIs]) for initial NSAID prescribing were 0.95 (0.93-0.97) for 1-2 orthopedic surgeon opioid prescriptions per THA/TKA procedure, 0.94 (0.92-0.97) for 3-4 prescriptions per procedure, and 0.91 (0.89-0.93) for 5+ opioid prescriptions per procedure (reference: <1 opioid prescription per procedure), while the RRs (95% CIs) for long-term opioid prescribing were 1.06 (1.04-1.08), 1.08 (1.06-1.11), and 1.13 (1.11-1.16), respectively. Variation in postoperative analgesic prescribing was observed across U.S. regions. For example, among NSAID-naïve individuals, the RR (95% CIs) for initial opioid prescribing were 0.98 (0.96-1.00) for Region 2 (New York), 1.09 (1.07-1.11) for Region 3 (Philadelphia), 1.07 (1.05-1.10) for Region 4 (Atlanta), 1.03 (1.01-1.05) for Region 5 (Chicago), 1.16 (1.13-1.18) for Region 6 (Dallas), 1.10 (1.08-1.12) for Region 7 (Kansas City), 1.09 (1.06-1.12) for Region 8 (Denver), 1.09 (1.07-1.12) for Region 9 (San Francisco), and 1.11 (1.08-1.13) for Region 10 (Seattle) (reference: Region 1 [Boston]). Hospital characteristics were not meaningfully associated with postoperative analgesic prescribing. The relationships between health system characteristics and postoperative analgesic prescribing were similar for NSAID-naïve and NSAID-prevalent participants.

Discussion

Future efforts aiming to improve the use of multimodal analgesia through increased NSAID prescribing and reduced long-term opioid prescribing following THA/TKA could consider targeting orthopedic surgeons with higher standardized opioid prescribing measures.

Conclusions

Orthopedic surgeon opioid prescribing measures and U.S. region were the greatest health system level predictors of initial, and long-term, prescribing of opioids and prescription NSAIDs among older Medicare beneficiaries following THA/TKA. These results can inform future studies that examine why variation in analgesic prescribing exists across geographic regions and levels of orthopedic surgeon opioid prescribing.

Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias

OBJECTIVES

To examine the relationship between changes in nursing staff-hours per resident-day and injury-related emergency department (ED) visits among assisted living (AL) residents with Alzheimer disease and related dementias (ADRD).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We leveraged a data set of AL community characteristics in Ohio linked to Medicare claims data from 2007 to 2015.

METHODS

We estimated Poisson models examining the relationships of personal care aide, registered nurse (RN), licensed practical nurse (LPN), and total nursing hours with injury-related ED visits. Models were adjusted for resident characteristics (ie, age, race, sex, dual eligibility, presence and number of chronic conditions), AL community characteristics (percentage of residents on Medicaid, average resident acuity), year fixed effects, and assisted living fixed effects. We examined all injury-related ED visits and injury-related ED visits resulting in hospital admission as separate outcomes.

RESULTS

The sample included 122,700 person-months, representing 12,144 fee-for-service Medicare beneficiaries with ADRD within 455 different AL communities in Ohio between 2007 and 2015. Median total nursing hours increased from 1.34 in 2007 to 1.69 in 2015. In the fully adjusted model, an increase in 1 RN-hour per resident-day was associated with a decrease in the risk of any injury-related ED visit (incidence rate ratio 0.59, 95% CI 0.36-0.96), representing a 53% decrease. Changes in RN-hours were not associated with injury-related inpatient hospitalizations. Changes in total nursing, LPN, and personal care aide hours were not associated with changes in the risk of injury-related ED visits or inpatient hospitalizations.

CONCLUSIONS AND IMPLICATIONS

Increases in RN staffing hours were associated with reduced injury-related ED use among AL residents with ADRD. RNs provide surveillance and care oversight that may help mitigate injury risk, and they are able to physically assess residents at the time of a fall and/or injury, which can preempt unnecessary ED transfers.

A comparison of dementia diagnoses and cognitive function measures in Medicare claims and the Minimum Data Set

BACKGROUND

Gold standard dementia assessments are rarely available in large real-world datasets, leaving researchers to choose among methods with imperfect but acceptable accuracy to identify nursing home (NH) residents with dementia. In healthcare claims, options include claims-based diagnosis algorithms, diagnosis indicators, and cognitive function measures in the Minimum Data Set (MDS), but few studies have compared these. We evaluated the proportion of NH residents identified with possible dementia and concordance of these three.

METHODS

Using a 20% random sample of 2018-2019 Medicare beneficiaries, we identified MDS admission assessments for non-skilled NH stays among individuals with continuous enrollment in Medicare Parts A, B, and D. Dementia was identified using: (1) Chronic Conditions Warehouse (CCW) claims-based algorithm for Alzheimer's disease and non-Alzheimer's dementia; (2) MDS active diagnosis indicators for Alzheimer's disease and non-Alzheimer's dementias; and (3) the MDS Cognitive Function Scale (CFS) (at least mild cognitive impairment). We compared the proportion of admissions with evidence of possible dementia using each criterion and calculated the sensitivity, specificity, and agreement of the CCW claims definition and MDS indicators for identifying any impairment on the CFS.

RESULTS

Among 346,013 non-SNF NH admissions between 2018 and 2019, 57.2% met criteria for at least one definition (44.7% CFS, 40.7% CCW algorithm, 26.0% MDS indicators). The MDS CFS uniquely identified the greatest proportion with evidence of dementia. The CCW claims algorithm had 63.7% sensitivity and 78.1% specificity for identifying any cognitive impairment on the CFS. Active diagnosis indicators from the MDS had lower sensitivity (47.0%), but higher specificity (91.0%).

CONCLUSIONS

Claims- and MDS-based methods for identifying NH residents with possible dementia have only partial overlap in the cohorts they identify, and neither is an obvious gold standard. Future studies should seek to determine whether additional functional assessments from the MDS or prescriptions can improve identification of possible dementia in this population.

Factors Associated With Mortality and Hospice Use Among Medicare Beneficiaries With Heart Failure Who Received Home Health Services

BACKGROUND

Although many Medicare beneficiaries with heart failure (HF) are discharged with home health services, little is known about mortality rates and hospice use in this group.

OBJECTIVES

To identify risk factors for 6-month mortality and hospice use among patients hospitalized due to HF who receive home health care, which could inform efforts to improve palliative and hospice use for these patients.

METHODS

A retrospective cohort analysis was conducted in a 100% national sample of Medicare fee-for-service beneficiaries with HF who were discharged to home health care between 2017 and 2018. Multivariable Cox regression models examined factors associated with 6-month mortality, and multivariable logistic regression models examined factors associated with hospice use at the time of death.

RESULTS

A total of 285,359 Medicare beneficiaries were hospitalized with HF and discharged with home health care; 15.5% (44,174) died within 6 months. Variables most strongly associated with mortality included: age > 85 years (hazard ratio [HR] 1.66, 95% CI 1.61-1.71), urgent/emergency hospital admission (HR 1.68, 1.61-1.76), and "serious" condition compared to "stable" condition (HR 1.64, CI 1.52-1.78). Among 44,174 decedents, 48.2% (21,284) received hospice care at the time of death. Those with lower odds of hospice use at death included patients who were: < 65 years (odds ratio [OR] 0.65, CI 0.59-0.72); of Black (OR 0.64, CI 0.59-0.68) or Hispanic race/ethnicity (OR 0.79, CI 0.72-0.88); and Medicaid-eligible (OR 0.80, CI 0.76-0.85).

CONCLUSIONS

Although many patients hospitalized for HF are at risk of 6-month mortality and may benefit from palliative and/or hospice services, our findings indicate under-use of hospice care and important disparities in hospice use by race/ethnicity and socioeconomic status.

Medicare Advantage enrollment and outcomes of post-acute nursing home care among patients with dementia

Enrollment in Medicare Advantage (MA) has been rapidly growing. We examined whether MA enrollment affects the outcomes of post-acute nursing home care among patients with Alzheimer's disease and related dementias (ADRD). We exploited year-to-year changes in MA penetration rates within counties from 2012 through 2019. After adjusting for patient-level characteristics and county fixed effects, we found that MA enrollment was not associated with days spent at home, nursing home days, likelihood of becoming a long-stay resident, hospital days, hospital readmission, or 1-year mortality. There was a modest increase in successful discharge to the community by 0.73 percentage points (relative increase of 2.4%) associated with a 10-percentage-point increase in MA enrollment. The results are consistent among racial/ethnic subgroups and dual-eligible patients. These findings suggest an imperative need to monitor and improve quality of managed care among enrollees with ADRD.

Geospatial Distribution of Racial Disparities in Influenza Vaccination in Nursing Homes

OBJECTIVES

This study aimed to assess the distribution of racial disparities in influenza vaccination between White and Black short-stay and long-stay nursing home residents among states and hospital referral regions (HRRs).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We included short-stay and long-stay older adults residing in US nursing homes during influenza seasons between 2011 and 2018. Included residents were aged ≥65 years and enrolled in Traditional Medicare. Analyses were conducted using resident-seasons, whereby residents could contribute to one or more influenza seasons if they resided in a nursing home across multiple seasons.

METHODS

Our comparison of interest was marginalized vs privileged racial group membership measured as Black vs White race. We obtained influenza vaccination documentation from resident Minimum Data Set assessments from October 1 through June 30 of a particular influenza season. Nonparametric g-formula was used to estimate age- and sex-standardized disparities in vaccination, measured as the percentage point (pp) difference in the proportions of individuals vaccinated between Black and White nursing home residents within states and HRRs.

RESULTS

The study included 7,807,187 short-stay resident-seasons (89.7% White and 10.3% Black) in 14,889 nursing homes and 7,308,111 long-stay resident-seasons (86.7% White and 13.3% Black) in 14,885 nursing homes. Among states, the median age- and sex-standardized disparity between Black and White residents was 10.1 percentage points (pps) among short-stay residents and 5.3 pps among long-stay residents across seasons. Among HRRs, the median disparity was 8.6 pps among short-stay residents and 5.0 pps among long-stay residents across seasons.

CONCLUSIONS AND IMPLICATIONS

Our analysis revealed that the magnitudes of vaccination disparities varied substantially across states and HRRs, from no disparity in vaccination to disparities in excess of 25 pps. Local interventions and policies should be targeted to high-disparity geographic areas to increase vaccine uptake and promote health equity.

Nurse Practitioner Care, Scope of Practice, and End-of-Life Outcomes for Nursing Home Residents With Dementia

Importance

Nursing home residents with Alzheimer disease and related dementias (ADRD) often receive burdensome care at the end of life. Nurse practitioners (NPs) provide an increasing share of primary care in nursing homes, but how NP care is associated with end-of-life outcomes for this population is unknown.

Objectives

To examine the association of NP care with end-of-life outcomes for nursing home residents with ADRD and assess whether these associations differ according to state-level NP scope of practice regulations.

Design, Setting, and Participants

This cohort study using fee-for-service Medicare claims included 334 618 US nursing home residents with ADRD who died between January 1, 2016, and December 31, 2018. Data were analyzed from April 6, 2015, to December 31, 2018.

Exposures

Share of nursing home primary care visits by NPs, classified as minimal (<10% of visits), moderate (10%-50% of visits), and extensive (>50% of visits). State NP scope of practice regulations were classified as full vs restrictive in 2 domains: practice authority (authorization to practice and prescribe independently) and do-not-resuscitate (DNR) authority (authorization to sign DNR orders).

Main Outcomes and Measures

Hospitalization within the last 30 days of life and death with hospice. Linear probability models with hospital referral region fixed effects controlling for resident characteristics, visit volume, and geographic factors were used to estimate whether the associations between NP care and outcomes varied across states with different scope of practice regulations.

Results

Among 334 618 nursing home decedents (mean [SD] age at death, 86.6 [8.2] years; 69.3% female), 40.5% received minimal NP care, 21.4% received moderate NP care, and 38.0% received extensive NP care. Adjusted hospitalization rates were lower for residents with extensive NP care (31.6% [95% CI, 31.4%-31.9%]) vs minimal NP care (32.3% [95% CI, 32.1%-32.6%]), whereas adjusted hospice rates were higher for residents with extensive (55.6% [95% CI, 55.3%-55.9%]) vs minimal (53.6% [95% CI, 53.3%-53.8%]) NP care. However, there was significant variation by state scope of practice. For example, in full practice authority states, adjusted hospice rates were 2.88 percentage points higher (95% CI, 1.99-3.77; P < .001) for residents with extensive vs minimal NP care, but the difference between these same groups was 1.77 percentage points (95% CI, 1.32-2.23; P < .001) in restricted practice states. Hospitalization rates were 1.76 percentage points lower (95% CI, -2.52 to -1.00; P < .001) for decedents with extensive vs minimal NP care in full practice authority states, but the difference between these same groups in restricted practice states was only 0.43 percentage points (95% CI, -0.84 to -0.01; P < .04). Similar patterns were observed in analyses focused on DNR authority.

Conclusions and Relevance

The findings of this cohort study suggest that NPs appear to be important care providers during the end-of-life period for many nursing home residents with ADRD and that regulations governing NP scope of practice may have implications for end-of-life hospitalizations and hospice use in this population.

Medicare Advantage Health Risk Assessments Contribute Up To $12 Billion Per Year To Risk-Adjusted Payments

With Medicare Advantage (MA) enrollment surpassing 50 percent of Medicare beneficiaries, accurate risk-adjusted plan payment rates are essential. However, artificially exaggerated coding intensity, where plans seek to enhance measured health risk through the addition or inflation of diagnoses, may threaten payment rate integrity. One factor that may play a role in escalating coding intensity is health risk assessments (HRAs)-typically in-home reviews of enrollees' health status-that enable plans to capture information about their enrollees. In this study, we evaluated the impact of HRAs on Hierarchical Condition Categories (HCC) risk scores, variation in this impact across contracts, and the aggregate payment impact of HRAs, using 2019 MA encounter data. We found that 44.4 percent of MA beneficiaries had at least one HRA. Among those with at least one HRA, HCC scores increased by 12.8 percent, on average, as a result of HRAs. More than one in five enrollees had at least one additional HRA-captured diagnosis, which raised their HCC score. Potential scenarios restricting the risk-score impact of HRAs correspond with $4.5-$12.3 billion in reduced Medicare spending in 2020. Addressing increased coding intensity due to HRAs will improve the value of Medicare spending and ensure appropriate payment in the MA program.

Antibiotic Prescribing Patterns for Urinary Tract Infections and Pneumonia by Prescriber Type and Specialty in Nursing Home Care, 2016-2018

OBJECTIVE

To identify whether differences in antibiotic prescribing practices by prescriber type and specialization in nursing home (NH) care exist for urinary tract infection (UTI) and pneumonia.

DESIGN

Retrospective cohort.

SETTING AND PARTICIPANTS

This national study included antibiotic dispensings to traditional Medicare beneficiaries aged ≥65 years with UTI or pneumonia infections residing long-term (≥100 days) in US NHs between 2016 and 2018.

METHODS

Minimum Data Set assessment data were linked to Medicare data [Part D prescription drug, inpatient hospital (MedPAR), prescriber characteristics, and enrollment]. We compared antibiotic prescribing patterns by prescriber type [physician vs advanced practice practitioner (AP)] and NH specialization (≥90% vs <90% of all associated medication dispensings to NH residents). Antibiotic dispensing measures included the total number of dispensings and duration of therapy (median number of days supplied) by antibiotic class.

RESULTS

There were 264,735 antibiotic dispensings prescribed by 32,437 prescribers for 140,360 residents in 14,035 NHs. NH specialists were less likely to prescribe fluoroquinolones for UTI (22.9% NH specialist physician, 23.9% non-NH specialist physician, 21.3% NH specialist AP, 24.2% non-NH specialist AP), but more likely to prescribe fluoroquinolones for pneumonia (38.9%, 37.8%, 38.8%, 37.3%, respectively). Over time, NH specialists reduced fluoroquinolone prescribing for pneumonia to a greater extent than non-NH specialists. The duration of therapy was similar across prescriber groups for UTI, but longer among non-NH specialist APs for several antibiotic classes for pneumonia, including tetracyclines, glycopeptides and lipoglycopeptides, and metronidazole.

CONCLUSIONS AND IMPLICATIONS

There were differences in antibiotic prescribing patterns by prescriber type and specialization in NH care between 2016 and 2018. Understanding how antibiotic prescribing differs based on prescriber characteristics is essential to inform antibiotic stewardship efforts. Tailoring antibiotic stewardship efforts to prescribers by NH specialization is rational given differences in antibiotic prescribing patterns based on NH specialization.

Comparative safety of tramadol and other opioids following total hip and knee arthroplasty

BACKGROUND

Tramadol is increasingly used to treat acute postoperative pain among older adults following total hip and knee arthroplasty (THA/TKA). However, tramadol has a complex pharmacology and may be no safer than full opioid agonists. We compared the safety of tramadol, oxycodone, and hydrocodone among opioid-naïve older adults following elective THA/TKA.

METHODS

This retrospective cohort included Medicare Fee-for-Service beneficiaries ≥ 65 years with elective THA/TKA between January 1, 2010 and September 30, 2015, 12 months of continuous Parts A and B enrollment, 6 months of continuous Part D enrollment, and no opioid use in the 6 months prior to THA/TKA. Participants initiated single-opioid therapy with tramadol, oxycodone, or hydrocodone within 7 days of discharge from THA/TKA hospitalization, regardless of concurrently administered nonopioid analgesics. Outcomes of interest included all-cause hospitalizations or emergency department visits (serious adverse events (SAEs)) and a composite of 10 surgical- and opioid-related SAEs within 90-days of THA/TKA. The intention-to-treat (ITT) and per-protocol (PP) hazard ratios (HRs) for tramadol versus other opioids were estimated using inverse-probability-of-treatment-weighted pooled logistic regression models.

RESULTS

The study population included 2,697 tramadol, 11,407 oxycodone, and 14,665 hydrocodone initiators. Compared to oxycodone, tramadol increased the rate of all-cause SAEs in ITT analyses only (ITT HR 1.19, 95%CLs, 1.02, 1.41; PP HR 1.05, 95%CLs, 0.86, 1.29). Rates of composite SAEs were not significant across comparisons. Compared to hydrocodone, tramadol increased the rate of all-cause SAEs in the ITT and PP analyses (ITT HR 1.40, 95%CLs, 1.10, 1.76; PP HR 1.34, 95%CLs, 1.03, 1.75), but rates of composite SAEs were not significant across comparisons.

CONCLUSIONS

Postoperative tramadol was associated with increased rates of all-cause SAEs, but not composite SAEs, compared to oxycodone and hydrocodone. Tramadol does not appear to have a superior safety profile and should not be preferentially prescribed to opioid-naïve older adults following THA/TKA.

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma

Importance

Evacuation has been found to be associated with adverse outcomes among nursing home residents during hurricanes, but the outcomes for assisted living (AL) residents remain unknown.

Objective

To examine the association between evacuation and health care outcomes (ie, emergency department visits, hospitalizations, mortality, and nursing home visits) among Florida AL residents exposed to Hurricane Irma.

Design, Setting, and Participants

Retrospective cohort study using 2017 Medicare claims data. Participants were a cohort of Florida AL residents who were aged 65 years or older, enrolled in Medicare fee-for-service, and resided in 9-digit zip codes corresponding to US assisted living communities with 25 or more beds on September 10, 2017, the day of Hurricane Irma's landfall. Propensity score matching was used to match evacuated residents to those that sheltered-in-place based on resident and AL characteristics. Data were analyzed from September 2022 to February 2024.

Exposure

Whether the AL community evacuated or sheltered-in-place before Hurricane Irma made landfall.

Main Outcomes and Measures

Thirty- and 90-day emergency department visits, hospitalizations, mortality, and nursing home admissions.

Results

The study cohort included 25 130 Florida AL residents (mean [SD] age 81 [9] years); 3402 (13.5%) evacuated and 21 728 (86.5%) did not evacuate. The evacuated group had 2223 women (65.3%), and the group that sheltered-in-place had 14 556 women (67.0%). In the evacuated group, 42 residents (1.2%) were Black, 93 (2.7%) were Hispanic, and 3225 (94.8%) were White. In the group that sheltered in place, 490 residents (2.3%) were Black, 707 (3.3%) were Hispanic, and 20 212 (93.0%) were White. After 1:4 propensity score matching, when compared with sheltering-in-place, evacuation was associated with a 16% greater odds of emergency department visits (adjusted odds ratio [AOR], 1.16; 95% CI, 1.01-1.33; P = .04) and 51% greater odds of nursing home visits (AOR, 1.51; 95% CI, 1.14-2.00; P = .01) within 30 days of Hurricane Irma's landfall. Hospitalization and mortality did not vary significantly by evacuation status within 30 or 90 days after the landfall date.

Conclusions and Relevance

In this cohort study of Florida AL residents, there was an increased risk of nursing home and emergency department visits within 30 days of Hurricane Irma's landfall among residents from communities that evacuated before the storm when compared with residents from communities that sheltered-in-place. The stress and disruption caused by evacuation may yield poorer immediate health outcomes after a major storm for AL residents. Therefore, the potential benefits and harms of evacuating vs sheltering-in-place must be carefully considered when developing emergency planning and response.

Fall risk and cardiovascular outcomes of first-line antihypertensive medications in nursing home residents

BACKGROUND

Little evidence exists about the comparative effects of first-line antihypertensive medications (i.e., renin-angiotensin-aldosterone converting enzyme inhibitors (RAASi), amlodipine, or thiazide diuretics) in older adults with limited life expectancy. We compared the rates of injurious falls and short-term cardiovascular events between different first-line antihypertensive medication classes in adults receiving care in nursing homes (NH).

METHODS

This was a retrospective cohort of Medicare fee-for-service beneficiaries receiving care in NHs. Patients newly dispensed first-line antihypertensive medications were identified using Part D claims (2015-2018) and linked with clinical assessments (i.e., Minimum Data Set). Fall-related injuries (FRI), hip fractures, and major adverse cardiac events (MACE) outcomes were identified using hospitalization claims. Patients were followed from the date of antihypertensive dispensing until the occurrence of outcomes, death, disenrollment, or 6-month follow-up. Inverse-probability-of-treatment-weighted (IPTW) cause-specific hazards regression models were used to compare outcomes between patients who were new users of RAASi, amlodipine, or thiazides.

RESULTS

Our cohort included 16,504 antihypertensive users (RAASi, n = 9574; amlodipine, n = 5049; thiazide, n = 1881). Mean age was 83.5 years (± 8.2), 70.6% were female, and 17.2% were non-white race. During a mean follow-up of 5.3 months, 326 patients (2.0%) experienced an injurious fall, 1590 (9.6%) experienced MACE, and 2123 patients (12.9%) died. The intention-to-treat IPTW hazard ratio (HR) for injurious falls for amlodipine (vs RAASi) use was 0.85 (95% confidence interval (CI) 0.66-1.08) and for thiazides (vs RAASi) was 1.22 (95% CI 0.88-1.66). The rates of MACE were similar between those taking anti-hypertensive medications. Thiazides were discontinued more often than other classes; however, inferences were largely unchanged in as-treated analyses. Subgroup analyses were generally consistent.

CONCLUSIONS

Older adults with limited life expectancy experience similar rates of injurious falls and short-term cardiovascular events after initiating any of the first-line antihypertensive medications.

Use of Diabetes Medications before and after a Heart Failure-Related Hospitalization among Nursing Home Residents

OBJECTIVES

Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) offer cardiovascular benefits, whereas thiazolidinediones (TZDs) and sulfonylureas (SUs) increase cardiovascular risk. The objective of this study was to describe the use of SGLT-2is, GLP-1RAs, TZDs, and SUs before and after a heart failure (HF)-related hospitalization in nursing home (NH) residents with type 2 diabetes (T2D).

DESIGN

This was a cohort study using a 20% sample of Medicare claims linked with Minimum Data Set resident assessments.

SETTING AND PARTICIPANTS

The study population was long-stay NH residents with T2D and an HF-related hospitalization between January 1, 2013, and August 31, 2018. For individuals with multiple HF hospitalizations, 1 hospitalization was randomly selected.

METHODS

We ascertained diabetes medications using Medicare Part D claims during the 120 days before and after hospital discharge (or skilled nursing facility discharge, where applicable). We calculated (1) the proportion of study participants who received a medication class of interest during pre- and posthospitalization periods; (2) the proportion of continuous users; and (3) the proportion of posthospitalization users who were new users.

RESULTS

A total of 12,990 NH residents with T2D and an HF-related hospitalization were included (mean age 78 years, 66% female, 19% Black). Before hospitalization, 1.5% received TZDs, 14.1% received SUs, 1.2% received GLP-1RAs, and 0.3% received SGLT-2is. Among prehospitalization users of TZDs, SUs, GLP-1RAs, and SGLT-2is, 49%, 62%, 60%, and 40% continued the medications, respectively. Among posthospitalization users of TZDs, SUs, GLP-1RAs, and SGLT-2is, 37%, 10%, 28%, and 11%, respectively, were new users.

CONCLUSIONS

Among NH residents with hospitalized HF, GLP-1RAs and SGLT-2is were seldom used. TZDs and SUs were still used by many residents with T2D after HF hospitalizations.

IMPLEMENTATIONS

Barriers may exist in the use of newer diabetes medications to prevent heart failure in NH residents with T2D, which warrants further studies in older adults with multimorbidity.

Characteristics and End-of-Life Care Pathways of Decedents From a National Cohort of Assisted Living Residents

BACKGROUND

Assisted living (AL) is an increasingly common, place of care for dying persons. However, it remains unclear to what extent residents are able to age in place or if AL represents an additional transition before death.

OBJECTIVES

Examine the sociodemographic characteristics, comorbidities, health care utilization, and end-of-life care pathways of AL residents before death.

RESEARCH DESIGN

A national cohort study of fee-for-service Medicare beneficiaries residing in large AL communities (25+ beds) during the month of January 2017 with 3 years of follow-up, using administrative claims data.

SUBJECTS

268,812 AL residents.

MEASURES

Sociodemographic characteristics, comorbidities, and health care utilization at the end of life.

RESULTS

Between 2017 and 2019, 35.1% of the study cohort died. Decedents were more likely than the overall AL population to be 85 years old or older (76.5% vs. 59.5%), and diagnosed with Alzheimer's disease and related dementia (70.3% vs. 51.6%). Most decedents (96.2%) had some presence in AL during the last year of life, but over 1 in 5 left AL before the last month of life. Among those in AL on day 30 before death, nearly half (46.4%) died in place without any health care transition, while 13.2% had 3 or more transfers before dying.

CONCLUSIONS

AL is an important place of care for dying persons, especially for those with dementia. These findings indicate a need to assess existing policies and processes guiding the care of the frail and vulnerable population of dying AL residents.

Trajectories of care and outcomes of Veterans receiving home-based primary care

BACKGROUND

Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal care to patients with complex, chronic disabling disease. While enrollment is associated with lower hospitalization rates and costs, detailed trajectories have not been well described.

METHODS

We performed a longitudinal descriptive study of patients newly enrolled in VA HBPC in fiscal year (FY) 2015. We extracted demographics, comorbidities, functional status, and social supports from VA and Medicare data and examined patterns of care and clinical outcomes, including hospital, nursing home (NH), hospice use and mortality from FY2015-2017. We present results using descriptive statistics, alluvial plots, and heat maps.

RESULTS

We identified 10,571 HBPC enrollees in FY2015; mean age was 77.7. HBPC patients commonly had chronic medical conditions with high self-management burden (e.g., diabetes 48.2%) and disabling conditions such as dementia (39.3%). Over half had ≥2 deficits in activities of daily living, 46% had caregivers with functional limitations or no caregiver, and 25% resided in a socially deprived area. Patients experienced variable care trajectories. Mean time enrolled in HBPC was 331 days, 8.3% of patients were discharged after 3 months, and 22.8% stayed enrolled for over 2 years. Institutional health care use declined in the 6 months after initial enrollment: (e.g., hospital: 41%-25%, NH: 34%-11%). At 2 years, 36% of patients had died; among decedents, 58% received hospice and 72% died in a non-institutional setting. In the last 180 days of life, 84% of time was spent at home, and once enrolled in hospice, 97% of time was spent outside of institutional care.

CONCLUSIONS

HBPC patients experience highly variable care trajectories but on average have reductions in acute care use and spend a majority of time in non-institutional settings. These data allow for a nuanced understanding of HBPC, providing a platform for monitoring, evaluating, and improving program function.

Clinicians who primarily practice in nursing homes and outcomes among residents with urinary tract infection or pneumonia

Objective

Assess the association between clinicians who primarily practice in nursing homes (NHs) and 14-day resident outcomes following initial antibiotic dispensing for pneumonia or urinary tract infection (UTI).

Design

Retrospective cohort.

Setting

U.S. NHs.

Participants

NH residents aged ≥65 years who were prescribed antibiotics for pneumonia or UTI between 1 January 2016 and 30 November 2018.

Methods

Medicare fee-for-service claims were linked to Minimum Data Set data. Clinicians who primarily practiced in NHs prescribed ≥90% of Part D dispensings to NH residents. Outcomes included death, all-cause and infection-specific hospitalization, and subsequent antibiotic dispensing. Adjusted risk ratios were estimated using inverse-probability-of-treatment-weighted (IPTW) modified Poisson regression models adjusting for 53 covariates.

Results

The study population included 28,826 resident-years who were prescribed antibiotics for pneumonia and 106,354 resident-years who were prescribed antibiotics for UTI. Among the pneumonia group, clinicians who primarily practiced in NHs were associated with a greater risk of death (RR 1.3; 95%CLs 1.0, 1.6), lower risks of all-cause (RR 0.9; 95%CLs 0.8, 0.9) and infection-specific hospitalization (RR 0.8; 95%CLs 0.7, 0.9), and similar risk of subsequent antibiotic dispensing (RR 1.0; 95%CLs 1.0, 1.1) after IPTW. No meaningful associations were observed between clinicians who primarily practiced in NHs and outcomes among the UTI group.

Conclusions

Clinicians who primarily practiced in NHs were associated with a lower risk of hospitalization but greater risk of mortality for NH residents with pneumonia. Further examination is needed to better understand drivers of differences in infection-related outcomes based on clinicians' training and primary practice setting.

Comparison of Claims-Based Frailty Indices in U.S. Veterans 65 and Older for Prediction of Long-Term Institutionalization and Mortality

BACKGROUND

Frailty is increasingly recognized as a useful measure of vulnerability in older adults. Multiple claims-based frailty indices (CFIs) can readily identify individuals with frailty, but whether 1 CFI improves prediction over another is unknown. We sought to assess the ability of 5 distinct CFIs to predict long-term institutionalization (LTI) and mortality in older Veterans.

METHODS

Retrospective study conducted in U.S. Veterans ≥65 years without prior LTI or hospice use in 2014. Five CFIs were compared: Kim, Orkaby (Veteran Affairs Frailty Index [VAFI]), Segal, Figueroa, and the JEN-FI, grounded in different theories of frailty: Rockwood cumulative deficit (Kim and VAFI), Fried physical phenotype (Segal), or expert opinion (Figueroa and JFI). The prevalence of frailty according to each CFI was compared. CFI performance for the coprimary outcomes of any LTI or mortality from 2015 to 2017 was examined. Because Segal and Kim include age, sex, or prior utilization, these variables were added to regression models to compare all 5 CFIs. Logistic regression was used to calculate model discrimination and calibration for both outcomes.

RESULTS

A total of 3 million Veterans were included (mean age 75, 98% male participants, 80% White, and 9% Black). Frailty was identified for between 6.8% and 25.7% of the cohort with 2.6% identified as frail by all 5 CFIs. There was no meaningful difference between CFIs in the area under the receiver operating characteristic curve for LTI (0.78-0.80) or mortality (0.77-0.79).

CONCLUSIONS

Based on different frailty constructs, and identifying different subsets of the population, all 5 CFIs similarly predicted LTI or death, suggesting each could be used for prediction or analytics.

Identifying a National Cohort of Medicare Beneficiaries Residing in Assisted Living Settings: An Updated Method

OBJECTIVE

Present an updated approach to identifying Medicare beneficiaries residing in licensed assisted living (AL) settings in the United States.

DESIGN

Retrospective cohort study using a national list of licensed AL settings, US Postal Service (USPS) data, and enrollment, claims, and assessment data from the Centers for Medicare and Medicaid Services.

SETTING AND PARTICIPANTS

A total of 403,326 beneficiaries residing in 29,905 licensed AL settings.

METHODS

We identified every ZIP+4 code affiliated with each AL address. We then identified all of the Medicare beneficiaries with that ZIP+4 on January 1, 2019, and excluded beneficiaries in nursing homes and hospitals on that date. We identified beneficiaries who were "definitively" and "very likely AL residents" according to the number of addresses corresponding to the ZIP+4 in the USPS data, the capacity of the AL setting, and the presence of a claim or assessment indicating services were delivered in AL. We compared beneficiaries excluded during our new capacity restriction step (ie, "possibly neighbors") to those included as being "definitively" and "very likely AL residents" using standardized mean differences.

RESULTS

The cohort excluded (ie, "possibly neighbors") using our new step in the identification process appears to be younger and healthier than the cohorts we include as being "definitively" and "very likely AL residents." In addition, the cohort we identified through our added step of supplementing with claims and assessment data have similar demographics to the other cohorts we include, although they appear to be in poorer health.

CONCLUSIONS AND IMPLICATIONS

Leveraging licensed capacity information and supplementing with claims and assessment data produce greater confidence in the ability to accurately identify AL residents using ZIP+4 codes reported in Medicare administrative data.

Fall-related Injuries and Opioid Administration Among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers

OBJECTIVES

Opioid use is associated with fall-related injuries (FRI) among older adults, especially those with dementia. We examined FRI following changes in national opioid safety initiatives over 3 regulatory periods [preinitiatives baseline (period 1): October 2012 to June 2013; post-Veteran Affairs (VA) opioid safety initiative (period 2): January 2014 to November 2015; post-VA and CDC opioid prescribing guidelines (period 3): March 2017 to September 2018] among Department of VA Community Living Center (CLC) long-stay residents with dementia.

DATA

VA provided and purchased care records, Medicare claims, CLC Minimum Data Set (MDS) assessments. VA bar-code medication administration data, VA outpatient prescription refill data, and Medicare Part D data were used to capture medication from inpatient, outpatient, and Medicare sources.

SETTINGS AND PARTICIPANTS

A total of 12,229 long-stay CLC residents with dementia between October 2012 and September 2018.

METHODS

We applied Veteran-regulatory period level (1) generalized linear model to examine the unadjusted and adjusted trends of FRI, and (2) difference-in-difference model with propensity score weighting to examine the relationship between opioid safety initiatives and FRI in 3 regulatory periods. We applied propensity score weighting to enable the cohorts in periods 2 and 3 had similar indications for opioid administration as in period 1.

RESULTS

FRI prevalence per month among CLC residents with Alzheimer disease and related dementias decreased from 3.1% in period 1 to 1.6% and 1.2% in periods 2 and 3, and the adjusted probability of FRI was 17% and 40% lower in periods 2 and 3 compared with period 1. The any, incident, and continued opioid administration were significantly associated with higher FRI, whereas the differences in FRI probabilities between opioid and nonopioid users had no significant changes over the 3 regulatory periods.

CONCLUSIONS

FRI was reduced among CLC residents with Alzheimer disease and related dementias receiving care in VA CLCs over the 3 regulatory periods, but the FRI reduction was not significantly associated with opioid safety initiatives. Other interventions that potentially targeted falls are likely to have helped reduce these fall events. Future studies could examine whether opioid use reduction ultimately benefitted nursing home residents by focusing on other possible outcomes or whether such reduction only resulted in more untreated pain.

Examining transitions of care among nursing home residents with and without antipsychotic medication use

OBJECTIVES

This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population.

METHODS

This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated.

RESULTS

Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94-0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p < 0.01), emergency department (19.6% vs. 10.7%, p < 0.01), and different NH (1.5% vs. 0.4%, p < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use.

CONCLUSIONS

Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population.

Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia

INTRODUCTION

Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end-of-life care transfers. Advanced practice clinicians (APCs)-which include nurse practitioners and physician assistants-increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end-of-life care versus hospice utilization and hospitalization for older adults with ADRD.

METHODS

Using Medicare data, we identified nursing home- (N=517,490) and community-dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score-weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month.

RESULTS

For both nursing home- and community-dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates.

DISCUSSION

APCs are an important group of providers delivering end-of-life primary care to individuals with ADRD.

HIGHLIGHTS

For both nursing home- and community-dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life. Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume.

Adoption of sodium-glucose cotransporter-2 inhibitors among prescribers caring for nursing home residents

BACKGROUND

Sodium-glucose cotransporter-2 inhibitor (SGLT2I) use has increased among community-dwelling populations, but little is known about how clinicians have prescribed them for US nursing home (NH) residents. We described the adoption of SGLT2Is by prescribers caring for long-stay NH residents by clinician specialty and over time, compared with sulfonylureas, an older diabetes medication class.

METHODS

We conducted a retrospective cohort study of prescribers of SGLT2Is and sulfonylureas for all long-stay US NH residents aged 65 years or older (2017-2019). Using 100% of Medicare Part D claims linked to prescriber characteristics data, we identified all dispensings of SGLT2Is and sulfonylureas for long-stay NH residents and their associated prescribers. We described the distribution of prescriber specialties for each drug class over time as well as the number of NH residents prescribed SGLT2s versus sulfonylureas. We estimated the proportions of prescribers who prescribed both drug classes versus only sulfonylureas or only SGLT2Is.

RESULTS

We identified 36,427 unique prescribers (SGLT2I: N = 5811; sulfonylureas: N = 35,443) for 117,667 NH residents between 2017 and 2019. For both classes, family medicine and internal medicine physicians accounted for most prescriptions (75%-81%). Most clinicians (87%) prescribed only sulfonylureas, 2% prescribed SGLT2Is only, and 11% prescribed both. Geriatricians were least likely to prescribe only SGLT2Is. We observed an increase in the number of residents with SGLT2I use from n = 2344 in 2017 to n = 5748 in 2019.

CONCLUSIONS

Among NH residents, most clinicians have not incorporated SGLT2Is into their prescribing for diabetes, but the extent of use is increasing. Family medicine and internal medicine physicians prescribed the majority of diabetes medications for NH residents, and geriatricians were the least likely to prescribe only SGLT2Is. Future research should explore provider concerns regarding SGLT2I prescribing, particularly adverse events.

Evaluation of post-acute care and one-year outcomes among Medicare beneficiaries with hip fractures: a retrospective cohort study

BACKGROUND

Post-acute care (PAC) services after hospitalization for hip fracture are typically provided in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), or at home via home health care (HHC). Little is known about the clinical course following PAC for hip fracture. We examined the nationwide burden of adverse outcomes by PAC setting in the year following discharge from PAC for hip fracture.

METHODS

This retrospective cohort included Medicare Fee-for-Service beneficiaries > 65 years who received PAC services in U.S. SNFs, IRFs, or HHC following hip fracture hospitalization between 2012 and 2018. Individuals who had a fall-related injury (FRI) during PAC or received PAC services in multiple settings were excluded. Primary outcomes included FRIs, all-cause hospital readmissions, and death in the year following discharge from PAC. Cumulative incidences and incidence rates for adverse outcomes were reported by PAC setting. Exploratory analyses examined risk ratios and hazard ratios between settings before and after inverse-probability-of-treatment-weighting, which accounted for 43 covariates.

RESULTS

Among 624,631 participants (SNF, 67.78%; IRF, 16.08%; HHC, 16.15%), the mean (standard deviation) age was 82.70 (8.26) years, 74.96% were female, and 91.30% were non-Hispanic White. Crude incidence rates (95%CLs) per 1000 person-years were highest among individuals receiving SNF care for FRIs (SNF, 123 [121, 123]; IRF, 105 [102, 107]; HHC, 89 [87, 91]), hospital readmission (SNF, 623 [619, 626]; IRF, 538 [532, 544]; HHC, 418 [414, 423]), and death (SNF, 167 [165, 169]; IRF, 47 [46, 49]; HHC, 55 [53, 56]). Overall, rates of adverse outcomes generally remained higher among SNF care recipients after covariate adjustment. However, inferences about the group with greater adverse outcomes differed for FRIs and hospital readmissions based on risk ratio or hazard ratio estimates.

CONCLUSIONS

In this retrospective cohort study of individuals hospitalized for hip fracture, rates of adverse outcomes in the year following PAC were common, especially among SNF care recipients. Understanding risks and rates of adverse events can inform future efforts to improve outcomes for older adults receiving PAC for hip fracture. Future work should consider calculating risk and rate measures to assess the influence of differential time under observation across PAC groups.

Factors Associated With Days Away From Home in the Year After Major Surgery Among Community-living Older Persons

OBJECTIVE

To identify the factors associated with days away from home in the year after hospital discharge for major surgery.

BACKGROUND

Relatively little is known about which older persons are susceptible to spending a disproportionate amount of time in hospitals and other health care facilities after major surgery.

METHODS

From a cohort of 754 community-living persons, aged 70+ years, 394 admissions for major surgery were identified from 289 participants who were discharged from the hospital. Candidate risk factors were assessed every 18 months. Days away from home were calculated as the number of days spent in a health care facility.

RESULTS

In the year after major surgery, the mean (SD) and median (interquartile range) number of days away from home were 52.0 (92.2) and 15 (0-51). In multivariable analysis, 5 factors were independently associated with the number of days away from home: age 85 years and older, low score on the Short Physical Performance Battery, low peak expiratory flow, low functional self-efficacy, and musculoskeletal surgery. Based on the presence versus absence of these factors, the absolute mean differences in the number of days away from home ranged from 31.2 for age 85 years and older to 53.5 for low functional self-efficacy.

CONCLUSIONS

The 5 independent risk factors can be used to identify older persons who are particularly susceptible to spending a disproportionate amount of time away from home after major surgery, and a subset of these factors can also serve as targets for interventions to improve quality of life by reducing time spent in hospitals and other health care facilities.

Trends in Risk-Adjusted Initiation and Reduction of Opioid Use among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers

OBJECTIVE

Proper initiation and reduction of opioids is important in providing effective and safe pain relief to Veterans with dementia, including in Community Living Centers (CLCs). We examined the trends in aggregated monthly risk-adjusted opioid administration days and dosage over 3 opioid safety regulatory periods: pre-Opioid Safety Initiative period (October 1, 2012-June 30, 2013; period 1), pre-CDC Clinical Practice Guideline period (January 1, 2014-November 30, 2015, period 2) and post-Veterans Affairs Clinical Practice Guideline period (March 1, 2017-September 30, 2018; period 3).

DESIGN

A retrospective study between October 1, 2012, and September 30, 2018.

SETTINGS AND PARTICIPANTS

4995 long-stay CLC residents with dementia who had incident (incident cohort, n = 2609) or continued (continued opioid cohort, n = 2386) opioid administration in CLCs.

METHODS

CLC Minimum Data Set (MDS) assessments data and bar-code medication administration data were used. Opioid initiation was examined for incident opioid cohort and reduction was examined using continued opioid cohort. We first computed aggregated monthly risk-adjusted opioid administration days, opioid with benzodiazepine administration days and opioid dosage, and then examined risk-adjusted incident and continued opioid administration trends over the regulatory periods controlling for facility-level characteristics.

RESULTS

Among the incident opioid cohort, compared to period 1, there were 1.9 and 2.1 fewer risk-adjusted opioid administration days per month in periods 2 and 3, respectively; 1.5 fewer risk-adjusted days per month with opioid and benzodiazepine administration in both periods 2 and 3; and 2.2 and 3.7 morphine milligrams equivalent per day (MMED) lower risk-adjusted dosage in periods 2 and 3, respectively. Among the continued opioid cohort, compared to period 1, there were 1.6 and 2.9 fewer risk-adjusted days with opioid and benzodiazepine administration days per month in periods 2 and 3, respectively, and 5.3 MMED lower risk-adjusted dosage per month in period 3.

CONCLUSIONS AND IMPLICATIONS

CLC providers initiated and reduced opioid administration in fewer days and at lower dosage among Veterans with dementia across the regulatory periods. The result was likely due to systemic efforts from health care professionals, CLC administrators, and policy makers or VA central office, aiming to reduce opioid misuse and improve quality of care in nursing home residents with dementia. What is still unknown is whether pain was well controlled or nonpharmacologic treatments were utilized.

Post-Acute Care Setting After Hip Fracture Hospitalization and Subsequent Opioid Use in Older Adults

OBJECTIVE

Pain management in post-acute care (PAC) requires careful balance, with both opioid use and inadequate pain treatment linked to poor outcomes. We describe opioid use among older adults following discharge from PAC for hip fracture in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs).

DESIGN

Retrospective cohort.

SETTING AND PARTICIPANTS

Medicare beneficiaries with Medicare Provider Analysis (MedPAR) claims, aged 66 years and older with a hip fracture hospitalization between 2012 and 2018 followed by PAC in SNFs or IRFs and then discharge to the community.

METHODS

Individuals were followed from PAC discharge for up to 1 year to assess opioid use. Covariate-standardized risk ratios (RR) and risk differences (RD) for opioid use within 7 days of PAC discharge were estimated via parametric g-formula with modified Poisson regression, and hazard ratios (HRs) for any post-PAC opioid use and long-term opioid use via Fine-Gray sub-distribution hazards regression.

RESULTS

Of 101,021 individuals, 80% (n = 80,495) were discharged from SNFs and 20% (n = 20,526) from IRFs. Opioids were dispensed to 50,433 patients (50%) overall and the 1-year cumulative incidence was notably higher in IRF (68%) than SNF (46%) patients. The adjusted risk of discharge from PAC with an opioid was 41% lower after SNFs versus IRFs [RR: 0.59; 95% confidence limits (CLs): 0.57-0.61; and RD: -0.16; 95% CLs: -0.17 to -0.15]. The adjusted rate of any opioid use in the year after PAC discharge was 44% lower (HR: 0.56; 95% CLs: 0.54-0.57) and of long-term opioid use was 17% lower (HR: 0.83; 95% CLs: 0.80-0.87) after SNFs versus IRFs.

CONCLUSIONS AND IMPLICATIONS

Opioid use is highly prevalent upon discharge from PAC after hip fracture, with lower use after SNF versus IRF care. Future research should assess the benefits and harms of post-PAC opioid prescribing and whether care practices during PAC can be improved to optimize long-term opioid use.

Application of Instrumental Variable Analysis in Pediatric End-of-Life Research: A Case Study

Instrumental variable analysis (IVA) has been widely used in many fields, including health care, to determine the comparative effectiveness of a treatment, intervention, or policy. However, its application in pediatric end-of-life care research has been limited. This article provides a brief overview of IVA and its assumptions. It illustrates the use of IVA by investigating the comparative effectiveness of concurrent versus standard hospice care for reducing 1-day hospice enrollments. Concurrent hospice care is a relatively recent type of care enabled by the Affordable Care Act in 2010 for children enrolled in the Medicaid program and allows for receiving life-prolonging medical treatment concurrently with hospice care. The IVA was conducted using observational data from 18,152 pediatric patients enrolled in hospice between 2011 and 2013. The results indicated that enrollment in concurrent hospice care reduced 1-day enrollment by 19.3%.

Development and validation of the fall-related injury risk in nursing homes (INJURE-NH) prediction tool

BACKGROUND

Existing models to predict fall-related injuries (FRI) in nursing homes (NH) focus on hip fractures, yet hip fractures comprise less than half of all FRIs. We developed and validated a series of models to predict the absolute risk of FRIs in NH residents.

METHODS

Retrospective cohort study of long-stay US NH residents (≥100 days in the same facility) between January 1, 2016 and December 31, 2017 (n = 733,427) using Medicare claims and Minimum Data Set v3.0 clinical assessments. Predictors of FRIs were selected through LASSO logistic regression in a 2/3 random derivation sample and tested in a 1/3 validation sample. Sub-distribution hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated for 6-month and 2-year follow-up. Discrimination was evaluated via C-statistic, and calibration compared the predicted rate of FRI to the observed rate. To develop a parsimonious clinical tool, we calculated a score using the five strongest predictors in the Fine-Gray model. Model performance was repeated in the validation sample.

RESULTS

Mean (Q1, Q3) age was 85.0 (77.5, 90.6) years and 69.6% were women. Within 2 years of follow-up, 43,976 (6.0%) residents experienced ≥1 FRI. Seventy predictors were included in the model. The discrimination of the 2-year prediction model was good (C-index = 0.70), and the calibration was excellent. Calibration and discrimination of the 6-month model were similar (C-index = 0.71). In the clinical tool to predict 2-year risk, the five characteristics included independence in activities of daily living (ADLs) (HR 2.27; 95% CI 2.14-2.41) and a history of non-hip fracture (HR 2.02; 95% CI 1.94-2.12). Performance results were similar in the validation sample.

CONCLUSIONS

We developed and validated a series of risk prediction models that can identify NH residents at greatest risk for FRI. In NH, these models should help target preventive strategies.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BACKGROUND

Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults.

METHODS

We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions.

DISCUSSION

To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.

TRIAL REGISTRATION

Registered 05 May 2021, at ISRCTN #60,657,985.

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (see attached).

Increased Medicare Advantage Penetration Is Associated With Lower Postacute Care Use For Traditional Medicare Patients

Medicare Advantage (MA) plans, which accounted for 45 percent of total Medicare enrollment in 2022, are incentivized to minimize spending on low-value services. Prior research indicates that MA plan enrollment is associated with reduced postacute care use without adverse impacts on patient outcomes. However, it is unclear whether a rising MA enrollment level is associated with a change in postacute care use in traditional Medicare, especially given growing participation in traditional Medicare Alternative Payment Models that have been found to be associated with lower postacute care spending. We hypothesize that market-level MA expansion is associated with reduced postacute care use among traditional Medicare beneficiaries-a "spillover" effect of providers modifying their practice patterns in response to MA plans' incentives. We found increased MA market penetration associated with reduced postacute care use among traditional Medicare beneficiaries, without a corresponding increase in hospital readmissions. This association was generally stronger in markets with a greater share of traditional Medicare beneficiaries attributed to accountable care organizations, suggesting that policy makers should account for MA penetration when evaluating potential savings in Alternative Payment Models within traditional Medicare.

Comparison of Pimavanserin Versus Quetiapine for Hospitalization and Mortality Risk Among Medicare Beneficiaries with Parkinson's Disease Psychosis

Background

Pimavanserin is currently the only antipsychotic approved for Parkinson's disease (PD) psychosis, yet its relative safety compared with treatment alternatives has not been thoroughly assessed.

Objectives

This study aimed to compare hospitalization and mortality risk in Medicare beneficiaries with PD receiving new prescriptions of pimavanserin or quetiapine for PD psychosis.

Methods

The study identified new users of pimavanserin and quetiapine from a 15% national sample of Medicare fee-for-service claims collected between May 1, 2016, and December 30, 2018. All-cause hospitalization and mortality were assessed in time-to-event regression models. Standardized mortality ratio weighting balanced pimavanserin and quetiapine users on baseline characteristics. Follow-up was censored at discontinuation, switch, disenrollment, or the end of the study period.

Results

There were 844 new pimavanserin users and 2505 new quetiapine users. The adjusted hazard ratios (95% confidence intervals [CIs]) for hospitalization at 30, 90, 180, and 365 days for pimavanserin versus quetiapine users were 0.59 (0.43-0.81), 0.56 (0.44-0.72), 0.63 (0.52-0.77), and 0.70 (0.60-0.83). The most common reasons for hospitalization were traumatic injury and sepsis. Hospitalizations for heart-related issues were higher with pimavanserin (P < 0.05). The adjusted hazard ratios (95% CIs) for all-cause mortality at 90, 180, and 365 days for pimavanserin versus quetiapine users were 0.73 (0.48-1.13), 0.80 (0.58-1.10), and 0.94 (0.74-1.19).

Conclusions

Risk of hospitalization was lower in pimavanserin users compared with quetiapine, and no difference in mortality was observed between pimavanserin and quetiapine. An active comparator analyses with treatment alternatives provided the most clinically relevant information for patients and physicians.

Injury-related emergency department use among assisted living residents with Alzheimer's disease and related dementias

BACKGROUND

Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer's disease and related dementias (ADRD) may be at particular risk. We compared injury-related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury-related ED visits among individuals with ADRD residing in ALs with memory care designation versus general AL.

METHODS

Using Medicare claims, we identified a cohort of fee-for-service beneficiaries who lived in AL in 2018 and resided in one of 20 states with site-specific information on memory care designation (n = 116,754). Outcomes included all injury-related ED visits and injury-related ED visits resulting in hospitalization in the calendar year 2018. We fit multilevel models of the association between ADRD and outcomes, adjusting for resident demographic characteristics and chronic conditions, license type characteristics, and AL characteristics, with random intercepts at the AL and license type levels. Among residents with ADRD, we examined whether memory care licensure was associated with injury-related ED visits.

RESULTS

The adjusted risk of injury-related ED use during the year was 20.1% (95% CI: 19.6%, 20.6%) for residents with ADRD compared to 16.1% for residents without ADRD (95% CI: 15.7%, 16.5%; p < 0.001). The adjusted risk of injury-related ED use ending in hospitalization was 4.9% (95% CI: 4.6%, 5.1%) for AL residents with ADRD and 3.9% for residents without ADRD (95% CI: 3.8%, 4.1%; p < 0.001). There were no significant differences in injury-related ED visits between residents with ADRD in ALs with memory care designation and residents in general AL.

CONCLUSIONS

Injury-related ED visits are common among AL residents with ADRD and residents in memory care, but residents in memory care AL experienced similar risks of injury as those in general AL. Further research should identify modifiable factors that can prevent injury among AL residents with ADRD.

Traumatic Brain Injury and Risk of Long-Term Nursing Home Entry among Older Adults: An Analysis of Medicare Administrative Claims Data

Traumatic brain injury (TBI) is a leading cause of injury-related disability among older adults, and there is increasing interest in post-discharge management as this population grows. We evaluated the association between TBI and long-term nursing home (NH) entry among a nationally representative sample of older adults. We identified 207,355 adults aged ≥65 years who received a diagnosis of either a TBI, non-TBI trauma, or were uninjured between January 2008 and June 2015 from a 5% sample of Medicare beneficiaries. The NH entry was operationalized as the first NH admission that resulted in a stay ≥100 days. Time to NH entry was calculated as the difference between the NH entry date and the index date (the date of TBI, non-TBI trauma, or inpatient/outpatient visit in the uninjured group). We used cause-specific Cox proportional hazards models with stabilized inverse probability of exposure weights to model time to NH entry as a function of injury in the presence of death as a competing risk and generated hazard ratios (HR) and 95% confidence intervals (CI). After excluding beneficiaries living in a NH at index, there were 60,600 TBI, 63,762 non-TBI trauma, and 69,893 uninjured beneficiaries in the sample. In weighted models, beneficiaries with TBI entered NHs at higher rates relative to the non-TBI trauma (HR 1.15; 95% CI 1.10, 1.20) and uninjured (HR 1.67; 95% CI 1.60, 1.74) groups. Future research should focus on interventions to retain older adult TBI survivors within the community.

Anticholinergic co-prescribing in nursing home residents using cholinesterase inhibitors: Potential deprescribing cascade

BACKGROUND

Polypharmacy may result from inappropriate prescribing of medications to treat adverse drug reactions (ADRs), i.e., "prescribing cascade." A potentially harmful prescribing cascade affecting those with severe dementia can result when anticholinergics are prescribed to manage side effects of cholinesterase inhibitors (ChEIs). We investigated 1) factors associated with co-prescribing of anticholinergics and ChEIs and 2) whether discontinuation of ChEIs was associated with subsequent discontinuation of anticholinergics-a potentially beneficial reversal or "deprescribing cascade."

METHODS

We conducted a retrospective analysis of linked Medicare Part A/B/D claims, Master Beneficiary Summary File, Minimum Data Set, Area Health Resource File, and Nursing Home Compare from 2015 to 2016. Subjects were Medicare beneficiaries residing in nursing homes, ≥65 years old with severe dementia admitted for non-skilled stays, who were prescribed ChEIs. Cross-sectional analysis evaluated factors associated with co-prescribing of anticholinergics with ChEIs. Longitudinal Cox proportional hazards regression examined whether discontinuation of ChEIs was associated with subsequent discontinuation of anticholinergics over a 1-year period.

RESULTS

We found 15% of our sample experienced co-prescribing of anticholinergics and ChEIs. Several resident and facility-level factors were associated with co-prescribing anticholinergics. Advancing age, minority race or ethnicity, end-stage renal disease, heart failure, and poor appetite were associated with a decreased likelihood of co-prescribing. Female sex, polypharmacy, and non-geriatric prescriber-type were associated with a higher likelihood of co-prescribing. In longitudinal analyses, we observed that discontinuation of ChEIs was associated with a reduced likelihood (HR 0.58 [95% CI, 0.47-0.71]) of discontinuing any medications with anticholinergic properties, except for bladder antimuscarinics (HR 1.32 [95% CI, 0.83-2.09]).

CONCLUSIONS

Younger, healthier older adults with dementia were more likely to experience co-prescribing anticholinergics and ChEIs. Discontinuation of anticholinergics was infrequent. Further research is needed to understand prescribers' ability to recognize and reverse potential prescribing cascades through deprescribing.

Impact of higher payments for rural home health episodes on rehospitalizations

PURPOSE

Home health agencies delivering care in rural counties face unique challenges when providing care to older adults; long travel times between each visit can limit the number of patients seen each day. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries without evaluating the policy's impact on patient outcomes.

METHODS

Using 100% Medicare data on postacute HH episodes from 2007 to 2014, we estimated the impact of higher payments on beneficiaries outcomes using difference-in-differences analysis, comparing rehospitalizations between rural and urban postacute HH episodes before and after 2010.

FINDINGS

Our sample included 5.6 million postacute HH episodes (18% rural). In the preperiod, the 30- and 60-day rehospitalization rates for urban HH episodes were 11.30% and 18.23% compared to 11.38% and 18.39% for rural HH episodes. After 2010, 30- and 60-day rehospitalization rates declined, 10.08% and 16.49% for urban HH episodes and 9.87% and 16.08% for rural HH episodes, respectively. The difference-in-difference estimate was 0.29 percentage points (P = .005) and 0.57 percentage points (P < .001) for 30- and 60-day rehospitalization, respectively.

CONCLUSIONS

Increasing payments resulted in a statistically significant reduction in rehospitalizations for rural postacute HH episodes. The add-on payment is set to sunset in 2022 and its impact on access and quality to HH for rural older adults should be reconsidered.

Pathway to Hospice: How Has Place of Care before Hospice Changed with the Growth of Hospice in the United States?

Background: Hospice use among Medicare decedents increased from 21.6% in 2000 to 51.6% in 2019. Whether this growth has been accompanied by more referrals to hospice directly from the community is not known. Objective: To assess trends in place of care before hospice enrollment. Design: Retrospective cohort from 2011 to 2018. Subjects: Medicare decedents age ≥66 years. Measure: Location of care before hospice enrollment in the last 90 days of life, defined as: the community with and without home health, short- or long-term nursing facility, or inpatient hospital. A county-level random effects model examined changes in enrollment from the community after adjusting for admitting diagnosis, age, race/ethnicity, sex, and Medicaid participation. Results: Among hospice enrollees (N = 7,650,933), 27.7% transitioned to hospice from the community, 31.8% transitioned from the hospital, and 10.1% transitioned after short- or long-term nursing facility stay. Rates of enrollment to hospice from the community remained stable from 35.1% in 2011 to 34.3% in 2018. After adjustment, the proportion enrolling in hospice from the community decreased by 1.2% (95% confidence interval -1.0% to 1.4%). Place of care before hospice enrollment in 2018 varied by hospice admitting diagnosis, with patients with cancer more likely to enroll from the community (39.5%) and patients with cerebrovascular accidents from the hospital (53.2%). Prior place of care varied by state, with Florida having the highest rate of the enrollment following hospitalization (47.8%). Conclusion: Despite the growth of hospice, the site of care before hospice enrollment has remained relatively stable and was strongly influenced by region.

Successful Community Discharge Among Older Adults With Traumatic Brain Injury Admitted to Inpatient Rehabilitation Facilities

Objective

To identify admission characteristics that predict a successful community discharge from an inpatient rehabilitation facility (IRF) among older adults with traumatic brain injury (TBI).

Design

In a retrospective cohort study, we leveraged probabilistically linked Medicare Administrative, IRF-Patient Assessment Instrument, and National Trauma Data Bank data to build a parsimonious logistic model to identify characteristics associated with successful discharge. Multiple imputation methods were used to estimate effects across linked datasets to account for potential data linkage errors.

Setting

Inpatient Rehabilitation Facilities in the U.S.

Participants

The sample included a mean of 1060 community-dwelling adults aged 66 years and older across 30 linked datasets (N=1060). All were hospitalized after TBI between 2011 and 2015 and then admitted to an IRF. The mean age of the sample was 79.7 years, and 44.3% of the sample was women.

Interventions

Not applicable.

Main Outcome Measures

Successful discharge home.

Results

Overall, 64.6% of the sample was successfully discharged home. A logistic model including 4 predictor variables: Functional Independence Measure motor (FIM-M) and cognitive (FIM-C) scores, pre-injury chronic conditions, and pre-injury living arrangement, that were significantly associated with successful discharge, resulted in acceptable discrimination (area under the curve: 0.76, 95% confidence interval [CI]: 0.72-0.81). Higher scores on the FIM-M (odds ratio [OR]:1.07, 95% CI: 1.05-1.09) and FIM-C (OR: 1.05, 95% CI: 1.02-1.08) were associated with greater odds of successful discharge, whereas living alone vs with others (OR: 0.46, 95% CI: 0.30-0.71) and a greater number of chronic conditions (OR: 0.94, 95% CI: 0.90-0.99) were associated with lower odds of successful discharge.

Conclusions

The results provide a parsimonious model for predicting successful discharge among older adults admitted to an IRF after a TBI-related hospitalization and provide clinically useful information to inform discharge planning.