State-Level Adverse Outcomes Among Long-Term Services and Supports Users With Alzheimer's Disease and Related Dementias

Home- and community-based services (HCBS) users, on average, experience hospitalizations more frequently than nursing facility residents. However, little is known about state-level variation in such adverse events among these groups. Using 2018 Medicare and Medicaid claims for dual-eligible beneficiaries with Alzheimer's disease and related dementias, we described hospitalization and emergency department (ED) visit rates among HCBS users and nursing facility residents and observed substantial state-level variation. In addition, consistent with prior evidence, we found more frequent hospitalizations and ED visits among HCBS users than nursing facility residents. The magnitude of this difference varied considerably across states, and the degree of variation was greatest among beneficiaries with six or more comorbid conditions. Our findings represent a crucial initial exploration of the state-level variation in adverse events among HCBS users and nursing facility residents, paving the way for further investigations into factors that contribute to this variability.

Factors associated with dietitian referrals to support long-term care residents advancing towards the end of life

BACKGROUND

Dietitians are central members of the multidisciplinary long-term care (LTC) healthcare team. The overall aim of this current investigation is to gain a better understanding of dietitian involvement in LTC resident's end-of-life care via referrals.

METHODS

Retrospective chart reviews for 164 deceased residents (mean age = 88.3 ± 7.3; 61% female) in 18 LTC homes in Ontario, Canada, identified dietitian referrals and documented eating challenges recorded over 2-week periods at four time points (i.e., 6 months, 3 months, 1 month and 2 weeks) prior to death. Nutrition care plans at the beginning of these time points were also noted. Logistic mixed effects regression models identified time-varying predictors of dietitian referrals. Bivariate tests identified associations between nutrition orders and dietitian referrals that occurred in the last month of life.

RESULTS

Nearly three-quarters (73%) of participants had at least one dietitian referral across the four observations. Referrals increased significantly with proximity to death; 45% of residents had a referral documented in the last 2 weeks of life. Dietitian referrals were associated with the number of eating challenges (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.27, 1.58). Comfort-focused nutrition care orders were significantly more common when a dietitian was referred (25%) compared with when a dietitian was not referred (12%) in the final month of life (p = 0.04).

CONCLUSIONS

Our findings suggest that dietitians are involved in end-of-life and comfort-focused nutrition care initiatives, yet they are not engaged consistently for this purpose. This presents a significant opportunity for dietitians to upskill and champion palliative approaches to nutrition care within the multidisciplinary LTC team.

Characteristics of first-time users of the nursing small-scale multifunctional home care service: a pooled cross-sectional study using Japanese long-term care insurance claims data from 2012 to 2019

OBJECTIVES

In April 2012, the Japanese government launched a new nursing service called the nursing small-scale multifunctional home care (NSMHC) to meet the nursing care demands of individuals with moderate-to-severe activities of daily living (ADLs) dysfunction and who require medical care, thereby allowing them to continue living in the community. We aimed to preliminarily analyse the characteristics of first-time users of NSMHC service.

DESIGN

This pooled cross-sectional study used the Japanese long-term care insurance (LTCI) claims data from the users' first use of NSMHC (from April 2012 to December 2019).

SETTING

NSMHC includes nursing home visits, home care, daycare, overnight stays and medical treatment.

PARTICIPANTS

The study population included LTCI beneficiaries who received their first long-term care requirement certification in Japan from April 2012 onwards, died between April 2012 and December 2019, and used any LTCI service at least once.

RESULTS

Among the 836 563 individuals who used any LTCI service at least once, 3957 (0.47%) used NSMHC. We analysed 3634 individuals without any missing data regarding long-term care requirement certification. Most individuals were aged 80 years or older, with 64.3% requiring care level 3 or above, indicating complete assistance with ADLs. Regarding ADLs in individuals with dementia, 70.6% were at level 2 or below, indicating they can live almost independently even with dementia. A large proportion of NSMHC users availed the service approximately 6 months before death, with no prior use of any LTCI services; they continued using the service for around 4 months, although some people continued to use NSMHC until their month of death.

CONCLUSIONS

Using individual data on nationwide LTCI, we described the characteristics of first-time users of NSMHC among those who died within 7.5 years from the first certification of care needs. Further studies are needed to investigate the effect of NSMHC use on user outcomes.

Long-term care use, hospitalizations and mortality during COVID-19 in Finland and Sweden: A nationwide register-based study in 2020

AIM

To describe long-term care (LTC) use in Finland and Sweden in 2020, by reporting residential entry and exit patterns including hospital admissions and mortality, compared with the 2018-2019 period and community-living individuals.

METHODS

From national registers in Finland and Sweden, all individuals 70+ were included. Using the Finnish and Swedish study populations in January 2018 as the standard population, we reported changes in sex- and age-standardized monthly rates of entry into and exit from LTC facilities, mortality and hospital admission among LTC residents and community-living individuals in 2020.

RESULTS

Around 850,000 Finns and 1.4 million Swedes 70+ were included. LTC use decreased in both countries from 2018 to 2020. In the first wave (March/April 2020), Finland experienced a decrease in LTC entry rates and an increase in LTC exit rates, both more marked than Sweden. This was largely due to short-term movements. Mortality rates peaked in April and December 2020 for LTC residents in Finland, while mortality peaked for both community-living individuals and LTC residents in Sweden. A decrease in hospital admissions from LTC facilities occurred in April 2020 and was less marked in Finland versus Sweden.

CONCLUSIONS

During the first wave of the pandemic mortality was consistently higher in Sweden. We also found a larger decrease in LTC use and, among LTC residents, a smaller decrease in hospital admissions in Finland than in Sweden. This study calls for assessing the health consequences of the differences observed between these two Scandinavian countries as part of the lessons from the COVID-19 pandemic.

Predictors of mortality shortly after entering a long-term care facility

OBJECTIVE

Moving into a long-term care facility (LTCF) requires substantial personal, societal and financial investment. Identifying those at high risk of short-term mortality after LTCF entry can help with care planning and risk factor management. This study aimed to: (i) examine individual-, facility-, medication-, system- and healthcare-related predictors for 90-day mortality at entry into an LTCF and (ii) create risk profiles for this outcome.

DESIGN

Retrospective cohort study using data from the Registry of Senior Australians.

SUBJECTS

Individuals aged ≥ 65 years old with first-time permanent entry into an LTCF in three Australian states between 01 January 2013 and 31 December 2016.

METHODS

A prediction model for 90-day mortality was developed using Cox regression with the purposeful variable selection approach. Individual-, medication-, system- and healthcare-related factors known at entry into an LTCF were examined as predictors. Harrell's C-index assessed the predictive ability of our risk models.

RESULTS

116,192 individuals who entered 1,967 facilities, of which 9.4% (N = 10,910) died within 90 days, were studied. We identified 51 predictors of mortality, five of which were effect modifiers. The strongest predictors included activities of daily living category (hazard ratio [HR] = 5.41, 95% confidence interval [CI] = 4.99-5.88 for high vs low), high level of complex health conditions (HR = 1.67, 95% CI = 1.58-1.77 for high vs low), several medication classes and male sex (HR = 1.59, 95% CI = 1.53-1.65). The model out-of-sample Harrell's C-index was 0.773.

CONCLUSIONS

Our mortality prediction model, which includes several strongly associated factors, can moderately well identify individuals at high risk of mortality upon LTCF entry.

[Analysing the Need for Long-Term Care: Potential of Data from Long-Term Care Assessments of the Bavarian Medical Service for Public Health Research and Practice]

BACKGROUND

Despite demographic changes, there is still no systematic and comparable differentiation of nursing care reporting on a small-scale level in Germany, where outpatient long-term care is depicted. This article presents findings of care assessment data of the Medical Service of Bavaria and draws conclusions for future reporting on nursing.

METHODS

For the analysis, anonymised initial long-term care assessments of the Bavarian Medical Service of 2019 were evaluated exemplarily using descriptive methods. The study describes the characteristics of persons with a care level recommendation, the distribution of care level categories, medical diagnoses and degree of independence in the areas of life.

RESULTS

The persons assessed were on average 80 years old. At the time of the initial assessment, the largest proportion of persons with an assigned care level lived in an outpatient setting. Care level (PG) 1 (slight impairment of independence or abilities) was assigned to 35.1% of the insured, PG 2 (considerable impairment) to 43.1%, PG 3 (severe impairment) to 16.6%, PG 4 and 5 (most severe impairment) were each rarely assigned at the time of the initial assessment (3.9% and 1.4%, respectively). Medical diagnoses were dominated by gait and mobility disorders, unspecified dementia, heart failure and senility. In particular, there were impairments in the areas of 'mobility' and 'organisation of everyday life and social contacts'.

CONCLUSIONS

The data available from the German Medical Service may be highly relevant to health research and policy and may provide a basis for planning interventions in long-term care.

Ascertaining the Francophone population in Ontario: validating the language variable in health data

BACKGROUND

Language barriers can impact health care and outcomes. Valid and reliable language data is central to studying health inequalities in linguistic minorities. In Canada, language variables are available in administrative health databases; however, the validity of these variables has not been studied. This study assessed concordance between language variables from administrative health databases and language variables from the Canadian Community Health Survey (CCHS) to identify Francophones in Ontario.

METHODS

An Ontario combined sample of CCHS cycles from 2000 to 2012 (from participants who consented to link their data) was individually linked to three administrative databases (home care, long-term care [LTC], and mental health admissions). In total, 27,111 respondents had at least one encounter in one of the three databases. Language spoken at home (LOSH) and first official language spoken (FOLS) from CCHS were used as reference standards to assess their concordance with the language variables in administrative health databases, using the Cohen kappa, sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV).

RESULTS

Language variables from home care and LTC databases had the highest agreement with LOSH (kappa = 0.76 [95%CI, 0.735-0.793] and 0.75 [95%CI, 0.70-0.80], respectively) and FOLS (kappa = 0.66 for both). Sensitivity was higher with LOSH as the reference standard (75.5% [95%CI, 71.6-79.0] and 74.2% [95%CI, 67.3-80.1] for home care and LTC, respectively). With FOLS as the reference standard, the language variables in both data sources had modest sensitivity (53.1% [95%CI, 49.8-56.4] and 54.1% [95%CI, 48.3-59.7] in home care and LTC, respectively) but very high specificity (99.8% [95%CI, 99.7-99.9] and 99.6% [95%CI, 99.4-99.8]) and predictive values. The language variable from mental health admissions had poor agreement with all language variables in the CCHS.

CONCLUSIONS

Language variables in home care and LTC health databases were most consistent with the language often spoken at home. Studies using language variables from administrative data can use the sensitivity and specificity reported from this study to gauge the level of mis-ascertainment error and the resulting bias.

Long-term care needs and hospitalization costs with long-term care insurance: a mixed-sectional study

Background

With the rapid aging of the population, the health needs of the older adult have increased significantly, resulting in the frequent occurrence of the "social hospitalization" problem, which has led to a rapid increase in hospitalization costs. This study investigates whether the "social hospitalization problem" arising from the long-term care needs can be solved through the implementation of long-term care insurance, thereby improving the overall health of the older adults and controlling the unreasonable increase in hospitalization costs.

Methods

The entropy theory was used as a conceptual model, based on data from the China Health and Retirement Longitudinal Study (CHARLS) in 2015 and 2018. The least-squares method was used to examine the relationship between long-term care needs and hospitalization costs, and the role that long-term care insurance implementation plays in its path of influence.

Results

The results of this study indicated that long-term care needs would increase hospitalization cost, which remained stable after a series of tests, such as replacing the core explanatory variables and introducing fixed effects. Through the intermediary effect test and mediated adjustment effect test, we found the action path of long-term care needs on hospitalization costs. Long-term care needs increases hospitalization costs through more hospitalizations. Long-term care insurance reduces hospitalization costs. Its specific action path makes long-term care insurance reduce hospitalization costs through a negative adjustment of the number of hospitalizations.

Conclusion

To achieve fair and sustainable development of long-term care insurance, the following points should be achieved: First, long-term care insurance should consider the prevention in advance and expand the scope of participation and coverage; Second, long-term care insurance should consider the control in the event and set moderate levels of treatment payments; Third, long-term care insurance should consider post-supervision and explore appropriate payment methods.

The risk of fractures after entering long-term care facilities

BACKGROUND

Stratifying residents at increased risk for fractures in long-term care facilities (LTCFs) can potentially improve awareness and facilitate the delivery of targeted interventions to reduce risk. Although several fracture risk assessment tools exist, most are not suitable for individuals entering LTCF. Moreover, existing tools do not examine risk profiles of individuals at key periods in their aged care journey, specifically at entry into LTCFs.

PURPOSE

Our objectives were to identify fracture predictors, develop a fracture risk prognostic model for new LTCF residents and compare its performance to the Fracture Risk Assessment in Long term care (FRAiL) model using the Registry of Senior Australians (ROSA) Historical National Cohort, which contains integrated health and aged care information for individuals receiving long term care services.

METHODS

Individuals aged ≥65 years old who entered 2079 facilities in three Australian states between 01/01/2009 and 31/12/2016 were examined. Fractures (any) within 365 days of LTCF entry were the outcome of interest. Individual, medication, health care, facility and system-related factors were examined as predictors. A fracture prognostic model was developed using elastic nets penalised regression and Fine-Gray models. Model discrimination was examined using area under the receiver operating characteristics curve (AUC) from the 20 % testing dataset. Model performance was compared to an existing risk model (i.e., FRAiL model).

RESULTS

Of the 238,782 individuals studied, 62.3 % (N = 148,838) were women, 49.7 % (N = 118,598) had dementia and the median age was 84 (interquartile range 79-89). Within 365 days of LTCF entry, 7.2 % (N = 17,110) of individuals experienced a fracture. The strongest fracture predictors included: complex health care rating (no vs high care needs, sub-distribution hazard ratio (sHR) = 1.52, 95 % confidence interval (CI) 1.39-1.67), nutrition rating (moderate vs worst, sHR = 1.48, 95%CI 1.38-1.59), prior fractures (sHR ranging from 1.24 to 1.41 depending on fracture site/type), one year history of general practitioner attendances (≥16 attendances vs none, sHR = 1.35, 95%CI 1.18-1.54), use of dopa and dopa derivative antiparkinsonian medications (sHR = 1.28, 95%CI 1.19-1.38), history of osteoporosis (sHR = 1.22, 95%CI 1.16-1.27), dementia (sHR = 1.22, 95%CI 1.17-1.28) and falls (sHR = 1.21, 95%CI 1.17-1.25). The model AUC in the testing cohort was 0.62 (95%CI 0.61-0.63) and performed similar to the FRAiL model (AUC = 0.61, 95%CI 0.60-0.62).

CONCLUSIONS

Critical information captured during transition into LTCF can be effectively leveraged to inform fracture risk profiling. New fracture predictors including complex health care needs, recent emergency department encounters, general practitioner and consultant physician attendances, were identified.

Potentially inappropriate prescriptions for poly-treated patients in long-term care facilities: retrospective pharmacoutilization analysis

BACKGROUND This study aimed to investigate, among elderly patients in long-term care (LTC) facilities, potentially inappropriate drug prescriptions, potentially interactions and verify whether they can be traced back to hospitalisations or accesses to the Emergency Department (ED). The study data were acquired by means of a case report form investigating the medication management process in LTCs. MATERIAL AND METHODS Analysis of pharmacutilisation in LTCFs patients aged ≥65 years on polypharmacy or excessive polypharmacy, January-July 2023. Data was extracted from a database (DB) containing the monthly prescriptions of medicines supplied by direct distribution (DD) to LTCs. The prevalence of PIMs was evaluated by applying the Beers and STOPP criteria to the medication profile of each patient. RESULTS The overall prevalence of polypharmacy and hyperpolypharmacy was 83% and 17%, respectively. PIMs were defined using Beers and STOPP criteria. The most frequent PIMs were proton pump inhibitors (19% e 15%), antiplatelets agent (17% e 13%) and non-associated sulfonamides (14% e 12%). Of the 1,921 PIMs, 121 were contraindicated or very serious (6%) and 1,800 were major (94%).The most common medicaments involved in drug-drug interaction are furosemide (21%), sertraline (19%), pantoprazole (16%) e trazodone (15%). LTCs participating in the study (56%) excluded polypharmacy as a cause of access to the ED and ADRs. Therefore no case was ever reported (100%). CONCLUSIONS Polypharmacy or excessive polypharmacy among elderly patients may increase PIMs and ADRs. A constant review of the therapeutic regimens and deprescribing decrease inappropriate use of medications and interactions, ADRs, and accesses to the ED with consequent reduction of pharmaceutical spending.

Cognitive Decline in Long-term Care Residents Before and During the COVID-19 Pandemic in Ontario, Canada

This study examines the incidence of cognitive decline among long-term care residents in Ontario before and during the COVID-19 pandemic.

Association of material deprivation with discharge location and length of stay after inpatient stroke rehabilitation in Ontario: a retrospective, population-based cohort study

BACKGROUND

Low socioeconomic status is associated with increased risk of stroke and worse poststroke functional status. The aim of this study was to determine whether socioeconomic status, as measured by material deprivation, is associated with direct discharge to long-term care or length of stay after inpatient stroke rehabilitation.

METHODS

We performed a retrospective, population-based cohort study of people admitted to inpatient rehabilitation in Ontario, Canada, after stroke. Community-dwelling adults (aged 19-100 yr) discharged from acute care with a most responsible diagnosis of stroke between Sept. 1, 2012, and Aug. 31, 2017, and subsequently admitted to an inpatient rehabilitation bed were included. We used a multivariable logistic regression model to examine the association between material deprivation quintile (from the Ontario Marginalization Index) and discharge to long-term care, and a multivariable negative binomial regression model to examine the association between material deprivation quintile and rehabilitation length of stay.

RESULTS

A total of 18 736 people were included. There was no association between material deprivation and direct discharge to long-term care (most v. least deprived: odds ratio [OR] 1.07, 95% confidence interval [CI] 0.89-1.28); however, people living in the most deprived areas had a mean length of stay 1.7 days longer than that of people in the least deprived areas (p = 0.004). This difference was not significant after adjustment for other baseline differences (relative change in mean 1.02, 95% CI 0.99-1.04).

INTERPRETATION

People admitted to inpatient stroke rehabilitation in Ontario had similar discharge destinations and lengths of stay regardless of their socioeconomic status. In future studies, investigators should consider further examining the associations of material deprivation with upstream factors as well as potential mitigation strategies.

Supplemental Nutrition Assistance Program Participation and Health Care Use in Older Adults : A Cohort Study

BACKGROUND

Older adults dually eligible for Medicare and Medicaid have particularly high food insecurity prevalence and health care use.

OBJECTIVE

To determine whether participation in the Supplemental Nutrition Assistance Program (SNAP), which reduces food insecurity, is associated with lower health care use and cost for older adults dually eligible for Medicare and Medicaid.

DESIGN

An incident user retrospective cohort study design was used. The association between participation in SNAP and health care use and cost using outcome regression was assessed and supplemented by entropy balancing, matching, and instrumental variable analyses.

SETTING

North Carolina, September 2016 through July 2020.

PARTICIPANTS

Older adults (aged ≥65 years) dually enrolled in Medicare and Medicaid but not initially enrolled in SNAP.

MEASUREMENTS

Inpatient admissions (primary outcome), emergency department visits, long-term care admissions, and Medicaid expenditures.

RESULTS

Of 115 868 persons included, 5093 (4.4%) enrolled in SNAP. Mean follow-up was approximately 22 months. In outcome regression analyses, SNAP enrollment was associated with fewer inpatient hospitalizations (-24.6 [95% CI, -40.6 to -8.7]), emergency department visits (-192.7 [CI, -231.1 to -154.4]), and long-term care admissions (-65.2 [CI, -77.5 to -52.9]) per 1000 person-years as well as fewer dollars in Medicaid payments per person per year (-$2360 [CI, -$2649 to -$2071]). Results were similar in entropy balancing, matching, and instrumental variable analyses.

LIMITATION

Single state, no Medicare claims data available, and possible residual confounding.

CONCLUSION

Participation in SNAP was associated with fewer inpatient admissions and lower health care costs for older adults dually eligible for Medicare and Medicaid.

PRIMARY FUNDING SOURCE

National Institutes of Health.

The Association of Race, Ethnicity, and Wages Among Registered Nurses in Long-term Care

OBJECTIVE

This study seeks to measure wage differences between registered nurses (RNs) working in long-term care (LTC) (eg, nursing homes, home health) and non-LTC settings (eg, hospitals, ambulatory care) and whether differences are associated with the characteristics of the RN workforce between and within settings.

STUDY DESIGN

This was a cross-sectional design. This study used the 2018 National Sample Survey of Registered Nurses (NSSRN) public-use file to examine RN employment and earnings.

METHODS

Our study population included a sample of 15,373 RNs who were employed at least 1000 hours in nursing in the past year and active in patient care. Characteristics such as race/ethnicity, type of RN degree completed, census region, and union status were included. Multiple regression analyses examined the effect of these characteristics on wages. Logistic regression was used to predict RN employment in LTC settings.

RESULTS

RNs in LTC experienced lower wages compared with those in non-LTC settings, yet this difference was not associated with racial/ethnic or international educational differences. Among RNs working in LTC, lower wages were associated with part-time work, less experience, lack of union representation, and regional wage differences.

CONCLUSION

Because RNs in LTC earn lower wages than RNs in other settings, policies to minimize pay inequities are needed to support the RN workforce caring for frail older adults.

Advance Directives State Requirements, Center Practices, and Participant Prevalence in Adult Day Services Centers: Findings From the 2016 National Study of Long-Term Care Providers

OBJECTIVES

Adult day services centers (ADSCs) may serve as an entrée to advance care planning. This study examined state requirements for ADSCs to provide advance directives (ADs) information to ADSC participants, ADSCs' awareness of requirements, ADSCs' practice of providing AD information, and their associations with the percentage of participants with ADs.

METHODS

Using the 2016 National Study of Long-Term Care Providers, analyses included 3,305 ADSCs that documented ADs in participants' files. Bivariate and linear regression analyses were conducted.

RESULTS

Nine states had a requirement to provide AD information. About 80.8% of ADSCs provided AD information and 41.3% of participants had documented ADs. There were significant associations between state requirements, awareness, and providing information with AD prevalence. State requirement was mediated by awareness.

DISCUSSION

This study found many ADSCs provided AD information, and ADSCs that thought their state had a requirement and provided information was associated with AD prevalence, regardless of state requirements.

Wound Care Consultation in Postacute/Long-term Care: Characteristics and Practice Implications

OBJECTIVE

To study the characteristics of residents in postacute (PA)/long-term care (LTC) facilities with wounds and prevalence of wound types other than pressure injuries (PIs).

METHODS

The authors conducted a retrospective review of all wound care consultations over 1 year at The New Jewish Home, a 514-bed academically affiliated facility in an urban setting. Investigators analyzed residents by age, sex, type of wound, presence of infection, and whether the resident was PA or LTC. Authors designated PIs as facility acquired or present on admission.

RESULTS

During the study period, 190 wound care consultations were requested; 74.7% of consults were for those in PA care. The average patient age was 76.3 years, and there were 1.7 wounds per resident receiving consultation. Of studied wounds, 53.2% were PIs, 15.8% surgical, 6.8% arterial, 6.3% soft tissue injury, 5.8% venous, 2.6% malignant wounds, and 2.1% diabetic ulcers; however, 11.6% of residents receiving consults had more than one wound type. In this sample, 13.2% of residents had infected wounds, and 76.2% of PIs were present on admission.

CONCLUSIONS

The wide variety of wounds in this sample reflects the medical complexity of this population. The transformation of LTC into a PA environment has altered the epidemiology of chronic wounds and increased demand for wound care expertise. These results challenge traditional perceptions of wound care centered on PIs. Given its importance, a wound care skill set should be required of all PA/LTC providers.

Multifaceted strategies for the control of COVID-19 outbreaks in long-term care facilities in Ontario, Canada

The novel coronavirus disease 2019 (COVID-19) has caused severe outbreaks in Canadian long-term care facilities (LTCFs). In Canada, over 80% of COVID-19 deaths during the first pandemic wave occurred in LTCFs. We sought to evaluate the effect of mitigation measures in LTCFs including frequent testing of staff, and vaccination of staff and residents. We developed an agent-based transmission model and parameterized it with disease-specific estimates, temporal sensitivity of nasopharyngeal and saliva testing, results of vaccine efficacy trials, and data from initial COVID-19 outbreaks in LTCFs in Ontario, Canada. Characteristics of staff and residents, including contact patterns, were integrated into the model with age-dependent risk of hospitalization and death. Estimates of infection and outcomes were obtained and 95% credible intervals were generated using a bias-corrected and accelerated bootstrap method. Weekly routine testing of staff with 2-day turnaround time reduced infections among residents by at least 25.9% (95% CrI: 23.3%-28.3%), compared to baseline measures of mask-wearing, symptom screening, and staff cohorting alone. A similar reduction of hospitalizations and deaths was achieved in residents. Vaccination averted 2-4 times more infections in both staff and residents as compared to routine testing, and markedly reduced hospitalizations and deaths among residents by 95.9% (95% CrI: 95.4%-96.3%) and 95.8% (95% CrI: 95.5%-96.1%), respectively, over 200 days from the start of vaccination. Vaccination could have a substantial impact on mitigating disease burden among residents, but may not eliminate the need for other measures before population-level control of COVID-19 is achieved.

Estimated Cardiorespiratory Hospitalizations Attributable to Influenza and Respiratory Syncytial Virus Among Long-term Care Facility Residents

IMPORTANCE

Older adults residing in long-term care facilities (LTCFs) are at a high risk of being infected with respiratory viruses, such as influenza and respiratory syncytial virus (RSV). Although these infections commonly have many cardiorespiratory sequelae, the national burden of influenza- and RSV-attributable cardiorespiratory events remains unknown for the multimorbid and vulnerable LTCF population.

OBJECTIVE

To estimate the incidence of cardiorespiratory hospitalizations that were attributable to influenza and RSV among LTCF residents and to quantify the economic burden of these hospitalizations on the US health care system by estimating their associated cost and length of stay.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used national Medicare Provider Analysis and Review inpatient claims and Minimum Data Set clinical assessments for 6 respiratory seasons (2011-2017). Long-stay residents of LTCFs were identified as those living in the facility for at least 100 days (index date), aged 65 years or older, and with 6 months of continuous enrollment in Medicare Part A were included. Follow-up occurred from the resident's index date until the first hospitalization, discharge from the LTCF, disenrollment from Medicare, death, or the end of the study. Residents could re-enter the sample; thus, long-stay episodes of care were identified. Data analysis was performed between January 1 and September 30, 2020.

EXPOSURES

Seasonal circulating pandemic 2009 influenza A(H1N1), human influenza A(H3N2), influenza B, and RSV.

MAIN OUTCOMES AND MEASURES

Cardiorespiratory hospitalizations (eg, asthma exacerbation, heart failure) were identified using primary diagnosis codes. Influenza- and RSV-attributable cardiorespiratory events were estimated using a negative binomial regression model adjusted for weekly circulating influenza and RSV testing data. Length of stay and costs of influenza- and RSV-attributable events were then estimated.

RESULTS

The study population comprised 2 909 106 LTCF residents with 3 138 962 long-stay episodes and 5 079 872 person-years of follow-up. Overall, 10 939 (95% CI, 9413-12 464) influenza- and RSV-attributable cardiorespiratory events occurred, with an incidence of 215 (95% CI, 185-245) events per 100 000 person-years. The cost of influenza- and RSV-attributable cardiorespiratory events was $91 055 393 (95% CI, $77 885 316-$104 225 470), and the length of stay was 56 858 (95% CI, 48 757-64 968) days.

CONCLUSIONS AND RELEVANCE

This study found that many cardiorespiratory hospitalizations among LTCF residents in the US were attributable to seasonal influenza and RSV. To minimize the burden these events place on the health care system and residents of LTCFs and to prevent virus transmission, additional preventive measures should be implemented.

Demographic Characteristics Driving Disparities in Receipt of Long-term Services and Supports in the Community Setting

BACKGROUND

Research suggests that growth in Black and Hispanic (minority) older adults' nursing home (NH) use may be the result of disparities in access to community-based and alternative long-term services and supports (LTSS).

OBJECTIVE

We aimed to determine whether minority groups receiving care in NHs versus the community had fewer differences in their functional needs compared with the differences in nonminority older adults, suggesting a disparity.

METHODS

We identified respondents aged 65 years or above with a diagnosis of Alzheimer disease or dementia in the 2016 Health and Retirement Study who reported requiring LTSS help. We performed unadjusted analyses to assess the difference in functional need between community and NH care. Functional need was operationalized using a functional limitations score and 6 individual activities of daily living. We compared the LTSS setting for minority older adults to White older adults using difference-in-differences.

RESULTS

There were 186 minority older adults (community=75%, NH=25%) and 357 White older adults (community=50%, NH=50%). Between settings, minority older adults did not differ in education or marital status, but were younger and had greater income in the NH versus the community. The functional limitations score was higher in NHs than in the community for both groups. Functional needs for all 6 activities of daily living for the minority group were greater in NHs compared with the community.

CONCLUSION

Functional need for minority older adults differed by setting while demographics varied in unexpected ways. Factors such as familial and financial support are important to consider when implementing programs to keep older adults out of NHs.

Association of Social Isolation of Long-term Care Facilities in the United States With 30-Day Mortality

Importance

Long-term care (LTC) residents may be susceptible to social isolation if living in facilities located in neighborhoods lacking social connection.

Objective

To characterize the social isolation of residents living in LTC facilities in the US.

Design, Setting, and Participants

This cross-sectional study included 730 524 LTC residents from 14 224 LTC facilities in 8652 zip code tabulation areas (ZCTAs) in the US in 2011. A nationwide LTC database with ZCTA data was linked to population-level geographic data from the US Census Bureau. Statistical analysis was performed from January 2019 to December 2020.

Exposures

The primary variable of interest was the social isolation of LTC neighborhoods defined as the percentage of households in the ZCTA with individuals aged 65 years or older who lived alone and categorized into quartiles of social isolation.

Main Outcomes and Measures

Maps were generated to illustrate geographic variation of LTC facilities at the ZCTA level by the quartile of socially isolated neighborhoods. Generalized estimating equations were used to estimate the adjusted likelihood that LTC facilities were located in areas of highest social isolation. We also used multilevel logistic regression models to assess the association between the social isolation of neighborhoods of LTC facilities and 30-day all-cause mortality after LTC admission. Subgroup analyses were conducted by race and ethnicity.

Results

Among 33 120 ZCTAs in the US, 8652 (26.1%) had at least 1 LTC facility. Among the 730 524 LTC residents included in the study's 14 224 LTC facilities, 458 136 (62.71%) were female, 610 802 (83.61%) were non-Hispanic White, and 419 654 (57.45%) were aged 80 years or older. Location of LTC facilities was associated with increasing levels of social isolation (quartile 1 = 9.72% [n = 840]; quartile 2 = 18.60% [n = 1607]; quartile 3 = 32.23% [n = 2784]; quartile 4 = 39.45% [n = 3408]; P < .001). In multivariate models, LTC facilities were 8 times more likely to be located in ZCTAs with the highest percentages of older adults residing in single-occupancy households (odds ratio [OR], 8.46; 95% CI, 7.44-9.65; P < .001), compared with ZCTAs with the lowest percentages. This association held across ZCTAs with a majority population of African American and Hispanic individuals, although it was strongest in ZCTAs with a majority population of White individuals. LTC residents entering facilities in neighborhoods with the highest levels of social isolation among older adults had a 17% higher risk of 30-day mortality (OR, 1.17; 95% CI, 1.10-1.25; P < .001) compared with those in neighborhoods with the lowest levels of social isolation among older adults.

Conclusions and Relevance

This study found that LTC facilities were often located in socially isolated neighborhoods, suggesting the need for special attention and strategies to keep LTC residents connected to their family and friends for optimal health.

Understanding Variation in Postacute Care: Developing Rehabilitation Service Areas Through Geographic Mapping

OBJECTIVE

The aims of the study were to demonstrate a method for developing rehabilitation service areas and to compare service areas based on postacute care rehabilitation admissions to service areas based on acute care hospital admissions.

DESIGN

We conducted a secondary analysis of 2013-2014 Medicare records for older patients in Texas (N = 469,172). Our analysis included admission records for inpatient rehabilitation facilities, skilled nursing facilities, long-term care hospitals, and home health agencies. We used Ward's algorithm to cluster patient ZIP Code Tabulation Areas based on which facilities patients were admitted to for rehabilitation. For comparison, we set the number of rehabilitation clusters to 22 to allow for comparison to the 22 hospital referral regions in Texas. Two methods were used to evaluate rehabilitation service areas: intraclass correlation coefficient and variance in the number of rehabilitation beds across areas.

RESULTS

Rehabilitation service areas had a higher intraclass correlation coefficient (0.081 vs. 0.076) and variance in beds (27.8 vs. 21.4). Our findings suggest that service areas based on rehabilitation admissions capture has more variation than those based on acute hospital admissions.

CONCLUSIONS

This study suggests that the use of rehabilitation service areas would lead to more accurate assessments of rehabilitation geographic variations and their use in understanding rehabilitation outcomes.

Disability-free survival after major cardiac surgery: a population-based retrospective cohort study

BACKGROUND

Cardiovascular research has traditionally been dedicated to "tombstone" outcomes, with little attention dedicated to the patient's perspective. We evaluated disability-free survival as a patient-defined outcome after cardiac surgery.

METHODS

We conducted a retrospective cohort study of patients aged 40 years and older who underwent coronary artery bypass grafting (CABG) or single or multiple valve (aortic, mitral, tricuspid) surgery in Ontario between Oct. 1, 2008, and Dec. 31, 2016. The primary outcome was disability (a composite of stroke, 3 or more nonelective hospital admissions and admission to a long-term care facility) within 1 year after surgery. We assessed the procedure-specific risk of disability using cumulative incidence functions, and the relative effect of covariates on the subdistribution hazard using Fine and Gray models.

RESULTS

The study included 72 824 patients. The 1-year incidence of disability and death was 2431 (4.6%) and 1839 (3.5%) for CABG, 677 (6.5%) and 539 (5.2%) for single valve, 118 (9.0%) and 140 (10.7%) for multiple valve, 718 (9.0%) and 730 (9.2%) for CABG and single valve, and 87 (13.1%) and 94 (14.1%) for CABG and multiple valve surgery, respectively. With CABG as the reference group, the adjusted hazard ratios for disability were 1.34 (95% confidence interval [CI] 1.21-1.48) after single valve, 1.43 (95% CI 1.18-1.75) after multiple valve, 1.38 (95% CI 1.26-1.51) after CABG and single valve, and 1.78 (95% CI 1.43-2.23) after CABG and multiple valve surgery. Combined CABG and multiple valve surgery, heart failure, creatinine 180 μmol/L or greater, alcohol use disorder, dementia and depression were independent risk factors for disability.

INTERPRETATION

The cumulative incidence of disability was lowest after CABG and highest after combined CABG and multiple valve surgery. Our findings point to a need for models that predict personalized disability risk to enable better patient-centred care.

[Changes in trends of diseases requiring long-term care in an aging community]

Objectives　The purpose of this study was to identify the changes in trends of leading diseases that require long-term care within a 5-year period in an area with a rapidly growing aging population.Methods　Data were obtained from newly registered primary insured individuals for long-term care insurance in Sapporo Minami Ward. There were 2,538 participants in FY2018 and 4,089 in FY2013 and FY2014.　Disorders diagnosed by a primary doctor were categorized into groups using a long-term care questionnaire survey from the Comprehensive Survey of Living Conditions. The difference in the frequency of diseases between the survey years was examined using a chi-square test.Results　In men, there was no significant change in the frequency of diseases that require long-term care within the 5-year period. In women, the frequency of cerebrovascular diseases significantly reduced (7.8% for FY2013 and 2014 vs. 5.6% for FY2018; P=0.008) and fractures and falls significantly increased (9.5% vs. 13.8%; P=0.001).　Regarding the diseases in the severe-level category of long-term care insurance, malignancy was the most frequent disorder in men, followed by stroke. In women, the frequency of fractures and falls increased (10.5% vs. 17.7%; P=0.002) and subsequently became the most frequently occurring disorder. Similarly, the frequency of fractures and falls increased significantly (9.2% vs. 12.5%; P=0.004) in the mild-level long-term care insurance category.Conclusion　For women, fractures and falls increased within the 5-year period, indicating the need to introduce a prompt preventive program. Lifestyle-related diseases such as malignancy and cerebrovascular diseases have become the main reason for shortening a healthy lifespan. This finding highlights the importance of preventing lifestyle-related diseases.

Differences in toe flexor strength and foot morphology between wheelchair dependent and ambulant older people in long-term care: a cross-sectional study

BACKGROUND

Hallux valgus, lesser toe deformity, and muscle weakness of the toe flexors contribute to falls in older people. This study aimed to examine the differences in toe flexor strength and foot morphology in older people requiring long-term care due to changes in the way they mobilize in everyday life.

METHODS

This study included 84 people aged ≥70 years without motor paralysis who underwent rehabilitation. They were divided into those who could mobilize without a wheelchair (walking group, n = 54) and those who used a wheelchair to mobilize (wheelchair group, n = 30). The presence or absence of diseases was confirmed, and hand grip strength, toe flexor strength, and foot morphology using the foot printer were measured. The presence of diseases, hand grip strength, toe flexor strength, and foot morphology were compared between the two groups. Multiple logistic analysis was performed with wheelchair dependence as the dichotomous outcome variable, and the percentages of each strength measure observed in the wheelchair group to the average hand grip and toe flexor strength measures in the walking group were compared.

RESULTS

No significant between-group difference in foot morphology was found. The factors related to the differences in ways of ambulating in daily life were history of fracture, heart disease, and toe flexor strength. After comparing the muscle strength of the wheelchair group with the mean values of the walking group, we found that the toe flexor strength was significantly lower than the hand grip strength.

CONCLUSIONS

Older people who used a wheelchair to mobilize have significantly less toe flexor strength than those who do not despite no significant difference in foot morphology. Use of a wheelchair is associated with a reduction in toe flexor strength.

Development of a predictive model for integrated medical and long-term care resource consumption based on health behaviour: application of healthcare big data of patients with circulatory diseases

BACKGROUND

Medical costs and the burden associated with cardiovascular disease are on the rise. Therefore, to improve the overall economy and quality assessment of the healthcare system, we developed a predictive model of integrated healthcare resource consumption (Adherence Score for Healthcare Resource Outcome, ASHRO) that incorporates patient health behaviours, and examined its association with clinical outcomes.

METHODS

This study used information from a large-scale database on health insurance claims, long-term care insurance, and health check-ups. Participants comprised patients who received inpatient medical care for diseases of the circulatory system (ICD-10 codes I00-I99). The predictive model used broadly defined composite adherence as the explanatory variable and medical and long-term care costs as the objective variable. Predictive models used random forest learning (AI: artificial intelligence) to adjust for predictors, and multiple regression analysis to construct ASHRO scores. The ability of discrimination and calibration of the prediction model were evaluated using the area under the curve and the Hosmer-Lemeshow test. We compared the overall mortality of the two ASHRO 50% cut-off groups adjusted for clinical risk factors by propensity score matching over a 48-month follow-up period.

RESULTS

Overall, 48,456 patients were discharged from the hospital with cardiovascular disease (mean age, 68.3 ± 9.9 years; male, 61.9%). The broad adherence score classification, adjusted as an index of the predictive model by machine learning, was an index of eight: secondary prevention, rehabilitation intensity, guidance, proportion of days covered, overlapping outpatient visits/clinical laboratory and physiological tests, medical attendance, and generic drug rate. Multiple regression analysis showed an overall coefficient of determination of 0.313 (p < 0.001). Logistic regression analysis with cut-off values of 50% and 25%/75% for medical and long-term care costs showed that the overall coefficient of determination was statistically significant (p < 0.001). The score of ASHRO was associated with the incidence of all deaths between the two 50% cut-off groups (2% vs. 7%; p < 0.001).

CONCLUSIONS

ASHRO accurately predicted future integrated healthcare resource consumption and was associated with clinical outcomes. It can be a valuable tool for evaluating the economic usefulness of individual adherence behaviours and optimising clinical outcomes.

Socioeconomic Inequalities in Home-Care Use Across Regional Long-term Care Systems in Europe

OBJECTIVES

We examine whether socioeconomic inequalities in home-care use among disabled older adults are related to the contextual characteristics of long-term care (LTC) systems. Specifically, we investigate how wealth and income gradients in the use of informal, formal, and mixed home-care vary according to the degree to which LTC systems offer alternatives to families as the main providers of care ("de-familization").

METHOD

We use survey data from SHARE on disabled older adults from 136 administrative regions in 12 European countries and link them to a regional indicator of de-familization in LTC, measured by the number of available LTC beds in care homes. We use multinomial multilevel models, with and without country fixed-effects, to study home-care use as a function of individual-level and regional-level LTC characteristics. We interact financial wealth and income with the number of LTC beds to assess whether socioeconomic gradients in home-care use differ across regions according to the degree of de-familization in LTC.

RESULTS

We find robust evidence that socioeconomic status inequalities in the use of mixed-care are lower in more de-familized LTC systems. Poorer people are more likely than the wealthier to combine informal and formal home-care use in regions with more LTC beds. SES inequalities in the exclusive use of informal or formal care do not differ by the level of de-familization.

DISCUSSION

The results suggest that de-familization in LTC favors the combination of formal and informal home-care among the more socioeconomically disadvantaged, potentially mitigating health inequalities in later life.

Socioeconomic Inequality in the Use of Long-Term Care among European Older Adults: An Empirical Approach Using the SHARE Survey

The increase in the proportion of elderly people in developed societies has several consequences, such as the rise in demand for long-term care (LTC). Due to cost, inequalities may arise and punish low-income households. Our objective is to examine socioeconomic inequalities in LTC utilization in Europe. We use the last wave from the Survey of Health, Aging, and Retirement in Europe SHARE (Munich Center for the Economics of Ageing, Munich, Germany), dated 2017, to analyze the impact of socioeconomic status (SES) on LTC. For this purpose, we construct logistic models and control for socioeconomic/household characteristics, health status, and region. Then, concentration indices are calculated to assess the distribution of LTC. Moreover, we also analyze horizontal inequity by using the indirect need-standardization process. We use two measures of SES (household net total income and household net wealth) to obtain robust results. Our findings demonstrate that informal care is concentrated among low-SES households, whereas formal care is concentrated in high-SES households. The results for horizontal concentration indices show a pro-rich distribution in both formal and informal LTC. We add new empirical evidence by showing the dawning of deep social inequalities in LTC utilization. Policymakers should implement policies focused on people who need care to tackle socioeconomic inequalities in LTC.

Heterogeneity in testing, diagnosis and outcome in SARS-CoV-2 infection across outbreak settings in the Greater Toronto Area, Canada: an observational study

BACKGROUND

Congregate settings have been disproportionately affected by coronavirus disease 2019 (COVID-19). Our objective was to compare testing for, diagnosis of and death after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection across 3 settings (residents of long-term care homes, people living in shelters and the rest of the population).

METHODS

We conducted a population-based prospective cohort study involving individuals tested for SARS-CoV-2 in the Greater Toronto Area between Jan. 23, 2020, and May 20, 2020. We sourced person-level data from COVID-19 surveillance and reporting systems in Ontario. We calculated cumulatively diagnosed cases per capita, proportion tested, proportion tested positive and case-fatality proportion for each setting. We estimated the age- and sex-adjusted rate ratios associated with setting for test positivity and case fatality using quasi-Poisson regression.

RESULTS

Over the study period, a total of 173 092 individuals were tested for and 16 490 individuals were diagnosed with SARS-CoV-2 infection. We observed a shift in the proportion of cumulative cases from all cases being related to travel to cases in residents of long-term care homes (20.4% [3368/16 490]), shelters (2.3% [372/16 490]), other congregate settings (20.9% [3446/16 490]) and community settings (35.4% [5834/16 490]), with cumulative travel-related cases at 4.1% (674/16490). Cumulatively, compared with the rest of the population, the diagnosed cases per capita was 64-fold and 19-fold higher among long-term care home and shelter residents, respectively. By May 20, 2020, 76.3% (21 617/28 316) of long-term care home residents and 2.2% (150 077/6 808 890) of the rest of the population had been tested. After adjusting for age and sex, residents of long-term care homes were 2.4 (95% confidence interval [CI] 2.2-2.7) times more likely to test positive, and those who received a diagnosis of COVID-19 were 1.4-fold (95% CI 1.1-1.8) more likely to die than the rest of the population.

INTERPRETATION

Long-term care homes and shelters had disproportionate diagnosed cases per capita, and residents of long-term care homes diagnosed with COVID-19 had higher case fatality than the rest of the population. Heterogeneity across micro-epidemics among specific populations and settings may reflect underlying heterogeneity in transmission risks, necessitating setting-specific COVID-19 prevention and mitigation strategies.

A comparison of 3 frailty measures and adverse outcomes in the intake home care population: a retrospective cohort study

BACKGROUND

In Ontario, Canada, nearly all home care patients are assessed with a brief clinical assessment (interRAI Contact Assessment [interRAI CA]) on admission. Our objective was to compare 3 frailty measures that can be operationalized using the interRAI CA.

METHODS

We conducted a retrospective cohort study using linked patient-level assessment and administrative data for all Ontario adult (≥ 18 yr) home care patients assessed with the interRAI CA in 2014. We employed multivariable logistic models to compare the Changes in Health, End-stage disease and Signs and Symptoms Scale for the Contact Assessment (CHESS-CA), Assessment Urgency Algorithm (AUA) and the Frailty Index for the Contact Assessment (FI-CA) that was created for this study. Our outcomes of interest were death, hospital admission and emergency department visits within 90 days, and assessor-rated need for comprehensive geriatric assessment (CGA).

RESULTS

In 2014, there were 228 679 unique adult home care patients in Ontario assessed with the interRAI CA. Controlling for age, sex and health region, being in a higher frailty level defined by any measure increased the likelihood of experiencing adverse outcomes. Among all assessments, CHESS-CA was best suited for predicting death and hospital admission, and either AUA or FI-CA for predicting perceived need for CGA. Previous emergency department visits were more predictive of future visits than frailty. Model fit was independent of whether the assessment was completed over the phone or in person.

INTERPRETATION

Frailty measures from the interRAI CA identified patients at higher risk for death, hospital admission and perceived need for CGA. In jurisdictions where the CHESS-CA and AUA are already built into the electronic home care platform, such as Ontario, patients identified as high risk should be prioritized for proactive referral and care planning, and may benefit from greater involvement of primary care and other health professionals in the circle of care.

Association of Medicaid Expansion Under the Patient Protection and Affordable Care Act With Use of Long-term Care

Importance

Medicaid expansion is associated with increased access to health services, increased quality of medical care delivered, and reduced mortality, but little is known about its association with use of long-term care.

Objective

To examine the association of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) with long-term care use among newly eligible low-income adults and among older adults whose eligibility did not change.

Design, Setting, and Participants

This difference-in-difference cohort study used data from the Health and Retirement Study, a nationally representative longitudinal survey of persons 50 years or older. Long-term care use from 2008 to 2012 was compared with use from 2014 to 2016 among low-income adults aged 50 to 64 years without Medicare coverage residing in states in which Medicaid coverage expanded in 2014 and those living in states without expansion. Low-income adults who were covered by Medicare and were ineligible for expanded Medicaid were also included in the analysis. Data were analyzed from January 15, 2018, to December 31, 2019.

Exposures

Residence in a state with Medicaid expansion in 2014.

Main Outcomes and Measures

Any home health care use or any nursing home use in 2014 or 2016. All estimates are weighted to account for the Health and Retirement Study sampling design.

Results

Among the 891 individuals likely eligible for expanded Medicaid, the mean (SD) age was 55.2 (3.1) years; 534 (53.4%) were women, 482 (49.5%) were married, and 661 (45.9%) were White non-Hispanic. Before the ACA-funded Medicaid expansion, 0.4% (95% CI, -0.3% to 1.1%) in expansion states and 1.0% (95% CI, -0.1% to 2.2%) in nonexpansion states used nursing homes, and 1.9% (95% CI, 0.4%-3.4%) in expansion states and 7.1% (95% CI, 4.7%-9.5%) in nonexpansion states used any formal home care. The ACA-funded Medicaid expansion was associated with an increase of 4.4 percentage points (95% CI, 2.8-6.1 percentage points) in the probability of any long-term care use among low-income, middle-aged adults, with increases in home health use (3.8 percentage points; 95% CI, 2.0-5.6 percentage points) and in any nursing home use (2.1 percentage points; 95% CI, 0.9-3.3 percentage points).

Conclusions and Relevance

In this study, ACA-funded Medicaid expansion was associated with an increase in any long-term care use among newly eligible low-income, middle-aged adults, suggesting that the population covered by the Medicaid expansion may have had unmet long-term care needs before expansion.

Farm working experience could reduce late-life dependency duration among Japanese older adults: The Yamanashi Healthy-Active Life Expectancy cohort study based on the STROBE guidelines

With the advance of medical care, the duration of dependency on nursing care in later life has increased worldwide. There is a question of whether farm work could extend or shorten the dependency duration. We investigated the association between farm work experience and the duration of dependency on nursing support or care in late life.We randomly selected 600 adults aged ≥65 years, who were independent and not hospitalized, as part of the Yamanashi Healthy-Active Life Expectancy cohort and followed them for 13 years. We defined the duration of dependency as the time from reception of long-term care insurance benefits to death, and we adjusted for multiple covariates.We analyzed data from 225 adults (139 men and 86 women) who died during the follow-up period. Ninety four had received long-term care benefits. Mean age was 79.6 years (standard deviation [SD]: 6.3) in individuals with farm work experience and 80.1 years (SD: 7.2) in individuals without farm work experience. The estimated duration of dependency on long-term care was 1.3 years (standard error [SE]: 0.4) in individuals with farm work experience vs 2.1 years (SE: 0.5) in individuals without farm work experience (P = .01). The estimated duration of dependency in individuals with farm work experience and without farm work experience was 0.4 years (SE: 0.5) vs 1.3 years (SE: 0.6) in men respectively (P = .03) and 1.6 years (SE: 0.9) vs 2.4 years (SE: 0.9) in women, respectively (P = .16). The sensitivity analysis yielded an estimated duration of 1.2 years (SE: 0.5) in those with farm work experience and 2.3 years (SE: 0.5) in those without farm work experience (P = .004).Individuals with farm work experience required less long-term care prior to death, suggesting that agricultural and physical activities promote health. Policymakers focusing on preventing the need for nursing care in older populations could consider promoting farming or gardening.

Risk Factors Associated With Mortality Among Residents With Coronavirus Disease 2019 (COVID-19) in Long-term Care Facilities in Ontario, Canada

IMPORTANCE

The coronavirus disease 2019 (COVID-19) pandemic has been particularly severe among individuals residing in long-term care (LTC) facilities. As of April 10, 2020, half of Canada's COVID-19 deaths had occurred in LTC facilities.

OBJECTIVE

To better understand trends and risk factors associated with COVID-19 death in LTC facilities in Ontario, Canada.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of 627 LTC facilities included 269 total individuals who died of COVID-19 in Ontario to April 11, 2020, and 83 individuals who died of COVID-19 in Ontario LTC facilities to April 7, 2020. Because population denominators were not available for LTC residents, they were approximated as the total number of LTC facility beds in Ontario (79 498), assuming complete occupancy.

EXPOSURES

Confirmed or suspected COVID-19 outbreaks; confirmed COVID-19 infection among residents and staff, diagnosed by real-time polymerase chain reaction testing.

MAIN OUTCOMES AND MEASURES

COVID-19-specific mortality incidence rate ratios (IRRs) for LTC residents were calculated with community-living Ontarians older than 69 years as the comparator group. Count-based regression methods were used to model temporal trends and to identify associations of infection risk among staff and residents with subsequent LTC resident death. Model-derived IRRs for COVID-19-specific mortality were generated through bootstrap resampling (1000 replicates) to generate median and 95% credible intervals for IRR over time.

RESULTS

Of 627 LTC facilities, 272 (43.4%) reported COVID-19 infection in residents or staff. Of 1 731 315 total individuals older than 69 years living in Ontario during the study period, 229 (<0.1%) died; of 79 498 potential residents in LTC facilities, 83 (0.1%) died. The IRR for COVID-19-related death in LTC residents was 13.1 (95% CI, 9.9-17.3) compared with community-living adults older than 69 years. The IRR increased sharply over time and was 87.3 (95% credible interval, 6.4-769.8) by April 11, 2020. Infection among LTC staff was associated with death among residents with a 6-day lag (eg, adjusted IRR for death per infected staff member, 1.17; 95% CI, 1.11-1.26).

CONCLUSIONS AND RELEVANCE

In this cohort study of COVID-19-related deaths during the pandemic in Ontario, Canada, mortality risk was concentrated in LTC residents and increased during a short period. Early identification of risk requires a focus on testing, providing personal protective equipment to staff, and restructuring the LTC workforce to prevent the movement of COVID-19 between facilities.

Risk Factors Associated With Mortality Among Residents With Coronavirus Disease 2019 (COVID-19) in Long-term Care Facilities in Ontario, Canada

IMPORTANCE

The coronavirus disease 2019 (COVID-19) pandemic has been particularly severe among individuals residing in long-term care (LTC) facilities. As of April 10, 2020, half of Canada's COVID-19 deaths had occurred in LTC facilities.

OBJECTIVE

To better understand trends and risk factors associated with COVID-19 death in LTC facilities in Ontario, Canada.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of 627 LTC facilities included 269 total individuals who died of COVID-19 in Ontario to April 11, 2020, and 83 individuals who died of COVID-19 in Ontario LTC facilities to April 7, 2020. Because population denominators were not available for LTC residents, they were approximated as the total number of LTC facility beds in Ontario (79 498), assuming complete occupancy.

EXPOSURES

Confirmed or suspected COVID-19 outbreaks; confirmed COVID-19 infection among residents and staff, diagnosed by real-time polymerase chain reaction testing.

MAIN OUTCOMES AND MEASURES

COVID-19-specific mortality incidence rate ratios (IRRs) for LTC residents were calculated with community-living Ontarians older than 69 years as the comparator group. Count-based regression methods were used to model temporal trends and to identify associations of infection risk among staff and residents with subsequent LTC resident death. Model-derived IRRs for COVID-19-specific mortality were generated through bootstrap resampling (1000 replicates) to generate median and 95% credible intervals for IRR over time.

RESULTS

Of 627 LTC facilities, 272 (43.4%) reported COVID-19 infection in residents or staff. Of 1 731 315 total individuals older than 69 years living in Ontario during the study period, 229 (<0.1%) died; of 79 498 potential residents in LTC facilities, 83 (0.1%) died. The IRR for COVID-19-related death in LTC residents was 13.1 (95% CI, 9.9-17.3) compared with community-living adults older than 69 years. The IRR increased sharply over time and was 87.3 (95% credible interval, 6.4-769.8) by April 11, 2020. Infection among LTC staff was associated with death among residents with a 6-day lag (eg, adjusted IRR for death per infected staff member, 1.17; 95% CI, 1.11-1.26).

CONCLUSIONS AND RELEVANCE

In this cohort study of COVID-19-related deaths during the pandemic in Ontario, Canada, mortality risk was concentrated in LTC residents and increased during a short period. Early identification of risk requires a focus on testing, providing personal protective equipment to staff, and restructuring the LTC workforce to prevent the movement of COVID-19 between facilities.

Modelling resource requirements and physician staffing to provide virtual urgent medical care for residents of long-term care homes: a cross-sectional study

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities.

METHODS

We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments.

RESULTS

There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each.

INTERPRETATION

The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.

Statin use and fall-related hospitalizations among residents of long-term care facilities: A case-control study

BACKGROUND

Statins are associated with muscle-related adverse events, but few studies have investigated the association with fall-related hospitalizations among residents of long-term care facilities (LTCFs).

OBJECTIVE

The objective of the study is to investigate whether statin use is associated with fall-related hospitalizations from LTCFs.

METHODS

A case-control study was conducted among residents aged ≥65 years admitted to hospital from 2013 to 2015. Cases (n = 332) were residents admitted for falls and fall-related injuries. Controls (n = 332) were selected from patients admitted for reasons other than cardiovascular and diabetes. Cases and controls were matched 1:1 by age (±2 years), index date of admission (±6 months), and sex. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression, after considering for history of falls, hypertension, dementia, functional comorbidity index, polypharmacy (≥9 regular preadmission medications), and fall-risk medications. Subanalyses were performed for individual statins, dementia, and statin intensity.

RESULTS

Overall, 43.1% of cases and 27.1% of controls used statins. Statins were associated with fall-related hospitalizations (aOR = 2.24, 95% CI 1.56-3.23), in particular simvastatin (aOR = 2.26, 95% CI 1.22-4.20) and atorvastatin (aOR = 2.08, 95% CI 1.33-3.24). Statins were associated with fall-related hospitalizations in residents with (aOR = 2.34, 95% CI 1.33-4.11) and without dementia (aOR = 2.30, 95% CI 1.46-3.63). There was no association between statin intensity and fall-related hospitalizations (aOR = 0.78, 95% CI 0.43-1.40).

CONCLUSION

This study suggests a possible association between statin use and fall-related hospitalizations among residents living in LTCFs. However, there was minimal evidence for a relationship between statin intensity and fall-related hospitalizations. Further research is required to substantiate these hypothesis-generating findings.

Nursing practice environment and care quality in nursing homes

A case study of the Pathway to Excellence in Long-Term Care model.

The process of obtaining informed consent to research in long term care facilities (LTCFs): An Observational Clinical Study

We examined the process of obtaining informed consent (IC) for clinical research purposes in long-term care facilities (LTCFs) in Rhode Island (RI), USA. We assessed factors that were associated with resident ability to consent, such as Brief Interview for Mental Status scores. We used a self-administered questionnaire to further understand the effect of LTCF staff evaluation of ability to consent on residents' autonomy and control over their medical decision making.Observational clinical studyLong-term care setting.LTCF personnel provided us with residents' names, as well as their professional assessment of resident ability to consent. We used Brief Interview for Mental Status (BIMS) scores to assess the cognitive capacity of all residents to assess, and compare it to the assessment provided by LTCF personnel. A logistic regression analysis was performed to determine the relationship between LTCF assessment of resident ability to consent and BIMS score or confirmed diagnosis of dementia as seen from residents' medical charts. A self-administered questionnaire was filled out by the personnel of 10 LTCFs across RI, USA.LTCF personnel in 9 out of 10 recruited facilities reported that their assessment of resident ability to consent was based on subjective assessment of the resident as alert and oriented. There was a statistically significant relationship between the LTCF assessment of resident ability to consent and previously diagnosed dementia (OR: 0.211, 95% CI 0.107-0.415). Therefore, as BIMS scores increased, the likelihood that the resident would be deemed able to consent by LTCF personnel also increased. Furthermore, there was a statistically significant relationship between LTCF assessment of resident ability to consent and BIMS scores (OR: 1.430, 95% CI 1.274-1.605).There is no standard on obtaining IC for research studies conducted in LTCFs. We recommend that standardizing the process of obtaining IC in LTCFs can enhance the ability to perform research with LTCF residents.

Regional variation in hospital care at the end-of-life of Dutch patients with lung cancer exists and is not correlated with primary and long-term care

OBJECTIVE

To examine the regional variation in hospital care utilization in the last 6 months of life of Dutch patients with lung cancer and to test whether higher degrees of hospital utilization coincide with less general practitioner (GP) and long-term care use.

DESIGN

Cross-sectional claims data study.

SETTING

The Netherlands.

PARTICIPANTS

Patients deceased in 2013-2015 with lung cancer (N = 25 553).

MAIN OUTCOME MEASURES

We calculated regional medical practice variation scores, adjusted for age, gender and socioeconomic status, for radiotherapy, chemotherapy, CT-scans, emergency room contacts and hospital admission days during the last 6 months of life; Spearman Rank correlation coefficients measured the association between the adjusted regional medical practice variation scores for hospital admissions and ER contacts and GP and long-term care utilization.

RESULTS

The utilization of hospital services in high-using regions is 2.3-3.6 times higher than in low-using regions. The variation was highest in 2015 and lowest in 2013. For all 3 years, hospital care was not significantly correlated with out-of-hospital care at a regional level.

CONCLUSIONS

Hospital care utilization during the last 6 months of life of patients with lung cancer shows regional medical practice variation over the course of multiple years and seems to increase. Higher healthcare utilization in hospitals does not seem to be associated with less intensive GP and long-term care. In-depth research is needed to explore the causes of the variation and its relation to quality of care provided at the level of daily practice.

Clients with long-term mental disabilities in a Swedish county—conditions of life, needs of support and unmet needs of service provided by the public health and social service sectors

Objective

The purpose of the study was to identify and describe conditions of life and needs of support and public service for clients with a mental disability in a Swedish county population.

Methods

Public health care and social service providers identified clients and completed a questionnaire concerning the clients’ conditions of life and their special needs. A consecutively recruited sample of clients completed a similar questionnaire.

Results

Totally, 1261 clients were identified. The prevalence of clients with mental disabilities was in the urban and rural areas, 6.4/1000 inhabitants and 4.5/1000 inhabitants, respectively. The most prevalent unmet need (42.9%) was to participate in social and scheduled activities. Almost half of the group was reported to need support in activities of daily living. Clients living in urban settings more often needed support with activities of daily living (P < 0.001), whereas clients living in rural settings more often needed support with job training (P < 0.001) or finding work (P < 0.01). Clients and psychiatric care providers reported the needs of the clients in the same areas; however, clients reported a fewer number of needs than did the care providers.

Conclusions

By using both psychiatric care and social service providers, effective case findings of clients with a mental disability were possible to achieve. In general, there was high agreement between psychiatric care providers and clients regarding the clients’ number of needs of support and their unmet needs of service. However, at the individual level, the agreement between client and psychiatric care providers was lower.

Eight-year post-trial follow-up of health care and long-term care costs of tele-based health coaching

OBJECTIVE

To evaluate the long-term effect of telephone health coaching on health care and long-term care (LTC) costs in type 2 diabetes (T2D) and coronary artery disease (CAD) patients.

DATA SOURCES/STUDY SETTING

Randomized controlled trial (RCT) data were linked to Finnish national health and social care registries and electronic health records (EHR). Post-trial eight-year economic evaluation was conducted.

STUDY DESIGN

A total of 1,535 patients (≥45 years) were randomized to the intervention (n = 1034) and control groups (n = 501). The intervention group received monthly telephone health coaching for 12 months. Usual health care and LTC were provided for both groups.

PRINCIPAL FINDINGS

Intention-to-treat analysis showed no significant change in total health and long-term care costs (intervention effect €1248 [3 percent relative reduction], CI -6347 to 2217) in the intervention compared to the control group. There were also no significant changes among subgroups of patients with T2D or CAD.

CONCLUSIONS

Health coaching had a nonsignificant effect on health care and long-term care costs in the 8-year follow-up among patients with T2D or CAD. More research is needed to study, which patient groups, at which state of the disease trajectory of T2D and cardiovascular disease, would best benefit from health coaching.

A systematic review on the causes of the transmission and control measures of outbreaks in long-term care facilities: Back to basics of infection control

BACKGROUND

The unique characteristics of long-term care facilities (LTCFs) including host factors and living conditions contribute to the spread of contagious pathogens. Control measures are essential to interrupt the transmission and to manage outbreaks effectively.

AIM

The aim of this systematic review was to verify the causes and problems contributing to transmission and to identify control measures during outbreaks in LTCFs.

METHODS

Four electronic databases were searched for articles published from 2007 to 2018. Articles written in English reporting outbreaks in LTCFs were included. The quality of the studies was assessed using the risk-of-bias assessment tool for nonrandomized studies.

FINDINGS

A total of 37 studies were included in the qualitative synthesis. The most commonly reported single pathogen was influenza virus, followed by group A streptococcus (GAS). Of the studies that identified the cause, about half of them noted outbreaks transmitted via person-to-person. Suboptimal infection control practice including inadequate decontamination and poor hand hygiene was the most frequently raised issue propagating transmission. Especially, lapses in specific care procedures were linked with outbreaks of GAS and hepatitis B and C viruses. About 60% of the included studies reported affected cases among staff, but only a few studies implemented work restriction during outbreaks.

CONCLUSIONS

This review indicates that the violation of basic infection control practice could be a major role in introducing and facilitating the spread of contagious diseases in LTCFs. It shows the need to promote compliance with basic practices of infection control to prevent outbreaks in LTCFs.

Developing a framework for performance assessment of the public long-term care system in Korea: methodological and policy lessons

BACKGROUND

Limited evidence exists on how to assess long-term care system performance. This study aims to report on the process and results of developing a performance assessment framework to evaluate the long-term care system financed by the public long-term care insurance in South Korea.

METHODS

The framework was developed through a six-step approach, including setting the goals and scope of performance assessment in the given policy context, reviewing existing performance frameworks, developing a framework with a wide range of potential indicators, refining the framework through a series of Delphi surveys and expert meetings, examining the feasibility of generated indicators through a pilot test, receiving the comments of stakeholders, and finalising the performance framework.

RESULTS

The finalised framework has 4 domains - coverage, quality of care, quality of life and system sustainability - and 28 indicators, including 10 core indicators to monitor long-term care system performance. Usability and feasibility along with policy relevance were important criteria in selecting these indicators. The proposed framework can be used to assess the performance of the long-term care system in Korea, and the framework and its methodological approach can be benchmarks for other countries developing their own framework.

CONCLUSIONS

It is critical to reconcile and prioritise various stakeholders' views and information needs as well as to balance methodological rigor with practical usefulness and feasibility in the development and implementation of a long-term care performance monitoring system.

Adapting Andersen's expanded behavioral model of health services use to include older adults receiving long-term services and supports

BACKGROUND

Andersen's Expanded Behavioral Model of Health Services Use describes factors associated with the use of long-term services and supports (LTSS). This model, however, has only been tested on the intent to use such services among African-American and White older adults and not the actual use. Given the increasing diversity of older adults in the U.S., the ability to conceptualize factors associated with actual use of LTSS across racial/ethnic groups is critical.

METHODS

We applied Andersen's Expanded model in the analysis of 2006-2010 qualitative data using multiple methods to understand both the relevancy of factors for older adults who currently use LTSS vs. those who intend to use LTSS (as described in Andersen's original exploration). We additionally explored differences in these factors across racial/ethnic groups and included Hispanic older adults in our analyses.

RESULTS

Four additional constructs linked with actual LTSS use emerged: losses and changes, tangible support, capability to provide informal support, and accessibility of informal support. Racial differences were seen in level of participation in decisions to use nursing home services (Not involved: 45% African-Americans vs. 24% Whites). Reports of LTSS use to avoid burdening one's family were greater among White older adults compared to African-American older adults.

CONCLUSIONS

Findings around decision-making and burden along with other constructs enhance our understanding of determinants that influence actual LTSS use and require targeted interventions.

Carbapenem-resistant Enterobacteriaceae: A retrospective review of treatment and outcomes in a long-term acute care hospital

BACKGROUND

Long-term acute care hospitals (LTACHs) have a unique patient population, with multiple risk factors for carbapenem-resistant Enterobacteriaceae (CRE) colonization and infection.

METHODS

We performed a retrospective analysis of patients in LTACHs who were diagnosed with and treated for CRE infections. Baseline data, antimicrobial treatment, and outcomes were collected in patients with bacteremia, health care-associated pneumonia, and complicated urinary tract infection/acute pyelonephritis due to CRE diagnosed between January 2017 and December 2017.

RESULTS

A total of 57 cases of CRE infection were identified over the study period, including 12 cases of bacteremia, 20 cases of health care-associated pneumonia, and 25 cases of complicated urinary tract infection/acute pyelonephritis. Patient had significant comorbidities: 31.5% with diabetes, 40.4% with heart failure, 29.8% with kidney disease, and 10% with solid tumors. The majority (56) of 57 patients received empiric antibiotics known to have activity against gram-negative bacteria, but only 38.6% had in vitro activity against the CRE organism in cultured specimens. A total of 78.9% of patients received monotherapy. Overall outcome was poor, with 28-day mortality across all infection sites of 17.5% in patients but up to 25% in patients with bacteremia.

CONCLUSIONS

In this retrospective analysis of our clinical experience treating CRE infections in an LTACH setting, we documented that CRE infections occur in patients with substantial comorbidities. Although clinical outcome remains of great concern, the 28-day mortality and rate of eradication of CRE in this study were comparatively better than other national estimates. Inappropriate empiric treatment may be one of many factors leading to overall poor treatment outcomes.

Effects of pressure ulcer prevention training among nurses in long-term care hospitals

BACKGROUND

Nurses caring for elderly patients with a high risk of pressure ulcer at long-term care hospitals require the necessary knowledge, behaviors, and attitudes regarding preventing pressure ulcers.

OBJECTIVES

To identify the effects of pressure ulcer prevention training on nurses' knowledge, behaviors, and attitudes regarding pressure ulcer prevention.

DESIGN

A comparison group pretest-posttest design.

SETTINGS

Long-term care hospitals in a metropolitan area of the Republic of Korea.

PARTICIPANTS

Participants were conveniently assigned to team-based learning (n = 30) or lecture-based learning (n = 30) groups.

METHODS

We examined pre-post differences in the scores for pressure ulcer prevention knowledge, behaviors, and attitudes in each group using the paired t-test. Additionally, pre-post difference scores were compared between the two groups using the independent samples t-test.

RESULTS

Both groups exhibited significant increases in scores for pressure ulcer prevention knowledge, behaviors, and attitudes after the intervention as compared before it. However, we found no significant differences in the pre-post difference scores for any of the variables between the two groups.

CONCLUSIONS

Pressure ulcer prevention training, regardless of whether it utilizes team-based or lecture-based learning, is useful for enhancing nurses' pressure ulcer prevention knowledge, behaviors, and attitudes. Further study is needed to verify the longitudinal effects of pressure ulcer prevention training on nurses' actual performance and the incidence of pressure ulcers among patients.

Social integration and loneliness among long-term care home residents: protocol for a scoping review

INTRODUCTION

Social well-being is associated with better physical and mental health. It is also important for quality of life, including from the perspectives of those living in long-term care (LTC) homes. However, given the characteristics of the LTC home environment and the people who live there, the nature and influence of social integration and loneliness, and strategies to address them, may differ in this population compared with those living in the community. The objective of this scoping review is to provide an overview of the nature and extent of research on social integration and loneliness among LTC home residents, including a summary of how these concepts have been operationalised and any evidence from specific groups.

METHODS AND ANALYSIS

This study protocol describes the methods of a scoping review of peer-reviewed literature related to social integration and loneliness among LTC home residents. A literature search was developed by an Information Specialist and will be conducted in MEDLINE(R) ALL (in Ovid, including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily) and then translated into CINAHL (EBSCO), PsycINFO (Ovid), Scopus, Sociological Abstracts (Proquest), Embase and Embase Classic (Ovid), Emcare Nursing (Ovid) and AgeLine (EBSCO). Two reviewers will independently screen titles and abstracts of articles identified in the search. Two reviewers will then independently review full text articles for inclusion. Data extraction will also be carried out in duplicate. We will engage LTC home community members, including residents, family and staff, to refine the review questions, assist in interpreting the results and participate in knowledge translation.

ETHICS AND DISSEMINATION

Ethics approval is not required. We will present findings at conferences and publish in a peer-reviewed journal. Ultimately, we hope to inform future observational and interventional research aimed at improving the health and quality of life of LTC home residents.

Evaluation of the Nursing Culture Assessment Tool for Pressure Injury Prevention: A Mixed-methods Study

The nursing culture in long-term care (LTC) settings may affect quality measures such as pressure injury (PrI) rates.

PURPOSE

The study was conducted to evaluate the relevance of an LTC facility's nursing culture to both their quality measures and their staff's perceptions of care in the context of PrI prevention.

METHODS

Directors of Nursing (DONs) in 4 purposively selected Medicare/Medicaid-certified skilled nursing facilities were invited by phone, agreed to participate in the 5-day project, and completed an initial 7-item, facility-related survey. Their staff completed the Nursing Culture Assessment Tool (NCAT), a pen-and-paper instrument that comprises 19 items regarding 6 principal dimensions of nursing culture (behaviors, expectations, teamwork, communication, satisfaction, and professional commitment) and participated in focus groups to discuss the NCAT and its findings using standardized probes of the perception of survey salience in relation to PrI prevention practices. Staff, including registered nurses, licensed practical nurses, and certified nursing assistants employed either part- or full-time at each facility, were eligible for study participation over a 5-day period. All data collection and analyses were conducted by the authors. Facility-related data were descriptive only. Analyses of variance were used to test differences in standardized NCAT scores by facility, and focus group transcripts were coded and subjected to structured thematic content analysis.

RESULTS

One hundred, nine (109) people completed the NCAT, and 47 participated in focus groups. NCAT scores varied significantly by facility (P value range .001-.027). Staff comments about their respective facility's results focused primarily on communication and teamwork and included both agreement or disagreement with the facility's high or low scores in the context of PrI prevention, as well as suggestions for instrument administration.

CONCLUSION

Examination of nursing culture using the NCAT can provide new and targeted perspectives on how frontline workers perceive barriers and facilitators to delivery of PrI prevention in LTC. To support the evidence base regarding their values and beliefs, future research on effective workplace change in LTC settings will require nuanced assessment of the meaning and impact of the nursing culture on worker performance.

Frailty and associated outcomes and resource utilization following in-hospital cardiac arrest

BACKGROUND

In-hospital cardiac arrest (IHCA) is common and associated with high mortality. Frailty is increasingly recognized as a predictor of worse prognosis among critically ill patients, but its association with outcomes and resource utilization following IHCA is unknown.

METHODS

We performed a retrospective analysis (2013-2016) of a prospectively collected registry from two hospitals of consecutive hospitalized adult patients with IHCA occurring on the hospital wards. We defined frailty using the Clinical Frailty Scale (CFS) score ≥5. CFS scores were based on validated medical review criteria. The primary outcome is hospital mortality. Secondary outcomes include return of spontaneous circulation (ROSC), discharge to long-term care, and hospital costs. We used multivariable logistic regression to adjust for known confounders.

RESULTS

We included 477 patients, and 124 (26.0%) had frailty. Frailty was associated with increased odds of hospital death (adjusted odds ratio [aOR]: 2.91 [95% confidence interval [CI]: 2.37-3.48) and discharge to long-term care (aOR 1.94 [95% CI: 1.57-2.32]). Compared with patients without frailty, patients with frailty had decreased odds of ROSC following IHCA (aOR 0.63 [95% CI: 0.41-0.93]). No difference in mean total costs was demonstrated between patients with and without frailty ($50,799 vs. $45,849). Frail patients did have higher cost-per-survivor ($947,546 vs. $161,550).

CONCLUSIONS

Frail individuals who experience an IHCA are more likely to die in hospital or be discharged to long-term care, and less likely to achieve ROSC in comparison with individuals who are not frail. The hospital costs per-survivor of IHCA are increased when frailty is present.

Insomnia, Benzodiazepine Use, and Falls among Residents in Long-term Care Facilities

Background: Falls are leading cause of injury among older people, especially for those living in long-term care facilities (LTCFs). Very few studies have assessed the effect of sleep quality and hypnotics use on falls, especially in Chinese LTCFs. The study aimed to examine the association between sleep quality, hypnotics use, and falls in institutionalized older people. Methods: We recruited 605 residents from 25 LTCFs in central Shanghai and conducted a baseline survey for sleep quality and hypnotics use, as well as a one-year follow-up survey for falls and injurious falls. Logistic regression models were applied in univariate and multivariate analysis. Results: Among the 605 participants (70.41% women, mean age 84.33 ± 6.90 years), the one-year incidence of falls and injurious falls was 21.82% and 15.21%, respectively. Insomnia (19.83%) and hypnotics use (14.21%) were prevalent. After adjusting for potential confounders, we found that insomnia was significantly associated with an increased risk of falls (adjusted risk ratio (RR): 1.787, 95% CI, 1.106–2.877) and the use of benzodiazepines significantly increased the risk of injurious falls (RR: 3.128, 95% CI, 1.541–6.350). Conclusion: In elderly LTCF residents, both insomnia and benzodiazepine use are associated with an increased risk of falls and injuries. Adopting non-pharmacological approaches to improve sleep quality, taking safer hypnotics, or strengthening supervision on benzodiazepine users may be useful in fall prevention.