Risk of Discharge to Lower-Quality Nursing Homes Among Hospitalized Older Adults With Alzheimer Disease and Related Dementias

Trends and Disparities in Alzheimer's Disease Mortality in the United States: The Impact of COVID-19

Background: Alzheimer's disease (AD) is the fifth leading cause of death for Americans older than 65. Though fluctuations have been noticed over the past two decades, the mortality of Alzheimer's patients increased considerably during the COVID-19 pandemic. This study aims to explore the temporal trends in AD-associated mortality (ADAM) and disparities in these trends, and we aim to discern changes to these trends during the COVID-19 pandemic. Methods: The CDC WONDER Multiple Cause-of-Death Public Use Records from 1999 to 2022 were used to extract population data on deaths related to AD and stratify them based on age, biological sex, race, ethnicity, place of death, census region, and state. ICD-10 codes G30.0, G30.1, G30.8, and G30.9 were used to identify AD-related mortality. Statistical analysis was performed using the Joinpoint Regression Program version 5.0.2. Results: We confirmed an increase in mortality rate in all races, sexes, places of death, age groups above 65, and states/census regions. Interestingly, the age-adjusted mortality rate (AAMR) of AD was consistently higher in females compared to males. Non-Hispanic whites had the highest AD mortality by race and ethnicity. At the intersection of race and biological sex, White females had the highest AAMR with AD. Lastly, we noted an increase in AD mortality at hospice facilities as compared to other places of death. Conclusions: Our findings demonstrate that the number of deaths due to AD was exacerbated by the recent pandemic and that White females were disproportionately affected. The disparities relating to ADAM uncovered in this study may assist healthcare administrators and policymakers in their decisions. Additionally, the findings might help initiate larger studies focusing on these disparities to explore novel risk/prognostic factors for AD.

Do Medicare Beneficiaries Under Accountable Care or Medicare Advantage Use Lower Quality Nursing Homes?

BACKGROUND

With the growing number of Medicare beneficiaries attributed to Accountable Care Organizations (ACO) or enrolled in Medicare Advantage (MA) and their financial incentives to lower the cost of the cared patients, it is essential to understand how these alternative payment models affect post-acute outcomes among beneficiaries, with or without dementia diagnoses. In this study, we examined the quality of skilled nursing facilities (SNFs) that beneficiaries entered after hospital discharge under different payment models.

STUDY PARTICIPANTS

Medicare beneficiaries who were discharged from hospitals and admitted to SNFs between 2013 and 2018.

KEY MEASURES

The exposure variable was a payment indicator, including ACO, MA, or non-ACO traditional Medicare (TM) fee-for-service. The dependent variable was high overall quality SNF, defined as with at least 4-star rating in the CMS Nursing Home Care Compare.

ANALYTIC PLAN

We examined the payer distribution by dementia diagnosis using ZIP Code Tabulation Areas (ZCTAs) fixed effects and adjusted for age, gender, and race. We also estimated the probabilities of entering high-quality SNF as a function of payer status and dementia diagnosis each year using hospital and ZCTA fixed effects and accounting for beneficiary-level covariates.

RESULTS

Among SNF admissions from 2013 to 2018, the share of ACO-attributed beneficiaries increased from 7.6% to 20.2%, MA enrollees increased from 25.2% to 32.8%, and non-ACO-attributed TM enrollees decreased from 67.2% to 47.3%. Consistently, ACO-attributed beneficiaries were the most likely, while MA enrollees were the least likely to enter high-quality SNFs, regardless of dementia diagnosis.

CONCLUSIONS

Our findings highlight significant differences in access to high-quality SNFs across Medicare payment models, with ACO-attributed beneficiaries consistently experiencing better access than their MA or traditional Medicare counterparts, regardless of dementia diagnosis. These results underscore the need for further investigation into how payment models influence care quality and access, particularly for vulnerable populations.

Impact of skilled nursing facility quality on Medicare beneficiaries with dementia: Evidence from vacancies

INTRODUCTION

People living with dementia are less likely to be admitted to high-rated nursing homes than people without dementia, despite their increased care needs. We investigated the effect of admission to nursing homes with higher staffing ratings on adverse outcomes for individuals with and without dementia post-hospitalization.

METHODS

Among Traditional Medicare beneficiaries discharged to nursing homes between 2011 and 2017, we examined the relationship between facility staffing star-ratings and short-term readmission and mortality using an instrumental variables approach to account for selection bias. The instrumental variables were the number of nearby vacant beds in high-rated facilities.

RESULTS

Admission to a higher-rated nursing home lowered post-discharge mortality risk at 90 days and reduced 30- and 90-day readmission. Point estimates were larger for people with dementia.

DISCUSSION

Findings underscore the need for enhancing direct care staffing in nursing homes and addressing access disparities, particularly for individuals with dementia who benefit significantly from high-quality care.

HIGHLIGHTS

We assessed how admission to nursing homes with higher staffing ratings impacted outcomes for individuals with and without dementia by exploiting variation in local bed vacancies as a source of quasi-random assignment. For both persons with and without dementia, adjusted short-term mortality and readmission rates were lower among those discharged to nursing homes with higher staffing ratings. Effects were larger for persons with dementia, indicating welfare loss from inequitable access to higher-rated nursing homes. Increasing staffing in nursing homes and reducing disparities for persons with dementia is essential for enhancing both equity and value.

Factors Influencing Hospitalization of Nursing Home Residents in Korea Using Regularized Negative Binomial Regression

The appropriateness of hospitalization for nursing home (NH) residents is still up for debate, with determining factors including timeliness, available treatment, healthcare staff, medication options in hospitals, and safety issues. Although the factors leading to hospitalization have been studied expansively, research on staffing is limited. Thus, this study aimed to investigate organizational predictors, nurse staffing, and government incentives and find important factors to hospitalization due to infection or disease among NH residents in Korea. A cross-sectional design was used, and data were collected via survey from a total of 51 NHs from August 27, 2021 to March 25, 2022. A total of 32 explanatory variables were included. The response variable was the count of hospitalized residents due to infection or disease. We analyzed data using least absolute shrinkage and negative binomial regression. We found that registered nurses' increased hours per resident day were related to decreased hospitalizations due to infection or disease. Appropriate retention and recruitment of nurse staffing with professional leadership should be performed to increase the quality of care for NH residents.

Racial/Ethnic Disparities in Hospital Readmission and Frequent Hospitalizations Among Medicare Beneficiaries With Alzheimer's Disease and Related Dementia: Traditional Medicare Versus Medicare Advantage

OBJECTIVES

Examine racial/ethnic disparities in 30-day readmission and frequent hospitalizations among Medicare beneficiaries with dementia in traditional Medicare (TM) versus Medicare Advantage (MA).

METHODS

In this case-control study, we used 2018-2019 TM and MA claims data. Participants included individuals 65+ with 2 years of continuous enrollment, diagnosis of dementia, a minimum of 4 office visits in 2018, and at least 1 hospitalization in 2019, (cases: TM [n = 36,656]; controls: MA [n = 29,366]). We conducted matching based on health-need variables and applied generalized linear models adjusting for demographics, health-related variables, and healthcare encounters.

RESULTS

TM was associated with higher odds of 30-day readmission (OR = 1.07 [CI: 1.02 to 1.12]) and frequent hospitalizations (OR = 1.10 [CI: 1.06 to 1.14]) compared to MA. Hispanic and Black enrollees in TM had higher odds of frequent hospitalizations compared with Hispanic and Black enrollees in MA, respectively (OR = 1.35 [CI: 1.19 to 1.54]) and (OR = 1.26 [CI: 1.13 to 1.40]). MA was associated with lower Hispanic-White and Black-White disparities in frequent hospitalizations by 5.8 (CI: -0.09 to -0.03) and 4.4 percentage points (PP; CI: -0.07 to -0.02), respectively. For 30-day readmission, there was no significant difference between Black enrollees in TM and MA (OR = 1.04 [CI: 0.92 to 1.18]), but Hispanic enrollees in TM had higher odds of readmission than Hispanics in MA (OR = 1.23 [CI: 1.06 to 1.43]). MA was associated with a lower Hispanic-White disparity in readmission by 1.9 PP (CI: -0.004 to -0.01).

DISCUSSION

MA versus TM was associated with lower risks of 30-day readmission and frequent hospitalizations. Moreover, MA substantially reduced Hispanic-White and Black-White disparities in frequent hospitalizations compared with TM.

Ready or Not: A Conceptual Model of Organizational Readiness for Embedded Pragmatic Dementia Research

The National Institute on Aging Alzheimer's Disease/Alzheimer's Disease and Related Dementias Research Implementation Milestones emphasize the need for implementation research that maximizes up-take and scale-up of evidence-based dementia care practices across settings, diverse populations, and disease trajectories. Organizational readiness for implementation is a salient consideration when planning and conducting embedded pragmatic trials, in which interventions are implemented by provider staff. The current article examines the conceptual and theoretical underpinnings of organizational readiness for implementation and the operationalization of this construct. We offer a preliminary conceptual model for explicating and measuring organizational readiness and describe the unique characteristics and demands of implementing evidence-based interventions targeting persons with dementia and/or their care partners. [Research in Gerontological Nursing, 17(3), 149-160.].

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

OBJECTIVE

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

DATA SOURCES

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

STUDY DESIGN

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

DATA COLLECTION

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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