Predictors of Discharges to a Nursing Home in a Hospital-Based Cohort

Predictors of 2-Year Post-Discharge Mortality in Hospitalized Older Patients

BACKGROUND

Understanding prognostic factors for adverse health outcomes is clinically relevant for improving treatment decision-making processes, potentially leading to enhanced patient prognosis. This secondary analysis of a prospective observational study aimed to identify independent factors associated with 2-year post-discharge mortality in acutely hospitalized older patients.

METHODS

All-cause mortality and date of death of 115 patients (83.3 ± 6.3 years, females: n = 75, 65.2%) admitted to acute geriatric wards were determined two years after hospital discharge through telephone interviews. Potential prognostic factors measured at hospital admission included demographic and clinical characteristics, nutritional, cognitive, and psychological status, Fried frailty phenotype, functioning in activities of daily living, locomotor capacity, and 24 h in-hospital mobility and objectively measured physical activity (PA) behaviors.

RESULTS

The 2-year mortality rate was 36.7% (n = 41). Univariate and multivariate Cox proportional hazards regression models revealed that mean daily PA level (hazards ratio (HR) = 0.59, 95% confidence interval (CI) 0.90-1.00; p = 0.042), frailty (HR = 3.39, 95% CI 1.20-9.51; p = 0.020), and underweight, in contrast to overweight (HR = 3.10, 95% CI 1.07-9.01; p = 0.038), at hospital admission were independently predictive of post-discharge mortality.

CONCLUSION

PA, frailty, and underweight at hospital admission should be considered when evaluating long-term survival prognosis, establishing risk profiles, and developing personalized care pathways in acute hospital care of older adults.

Does reducing out-of-pocket costs for children's surgical care protect families from poverty in Somaliland? A cross-sectional, national, economic evaluation modelling study

OBJECTIVES

An estimated 1.7 billion children around the world do not have access to safe, affordable and timely surgical care, with the financing through out-of-pocket (OOP) expenses being one of the main barriers to care. Our study modelled the impact of reducing OOP costs related to surgical care for children in Somaliland on the risk of catastrophic expenditures and impoverishment.

DESIGN AND SETTING

This cross-sectional nationwide economic evaluation modelled several different approaches to reduction of paediatric OOP surgical costs in Somaliland.

PARTICIPANTS AND OUTCOME MEASURES

A surgical record review of all procedures on children up to 15 years old was conducted at 15 surgically capable hospitals. We modelled two rates of OOP cost reduction (reduction of OOP proportion from 70% to 50% and from 70% to 30% reduction in OOP costs) across five wealth quintiles (poorest, poor, neutral, rich, richest) and two geographical areas (urban and rural). The outcome measures of the study are catastrophic expenditures and risk of impoverishment due to surgery. We followed the Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

We found that the risk of catastrophic and impoverishing expenditures related to OOP expenditures for paediatric surgery is high across Somaliland, but most notable in the rural areas and among the poorest quintiles. Reducing OOP expenses for surgical care to 30% would protect families in the richest wealth quintiles while minimally affecting the risk of catastrophic expenditure and impoverishment for those in the lowest wealth quintiles, particularly those in rural areas.

CONCLUSION

Our models suggest that the poorest communities in Somaliland lack protection against the risk of catastrophic health expenditure and impoverishment, even if OOP payments are reduced to 30% of surgical costs. A comprehensive financial protection in addition to reduction of OOP costs is required to prevent risk of impoverishment in these communities.

Sex Differences in Outcomes of Percutaneous Pulmonary Artery Thrombectomy in Patients With Pulmonary Embolism

BACKGROUND

The sex differences in use, safety outcomes, and health-care resource use of patients with pulmonary embolism (PE) undergoing percutaneous pulmonary artery thrombectomy are not well characterized.

RESEARCH QUESTION

What are the sex differences in outcomes for patients diagnosed with PE who undergo percutaneous pulmonary artery thrombectomy?

STUDY DESIGN AND METHODS

This retrospective cross-sectional study used national inpatient claims data to identify patients in the United States with a discharge diagnosis of PE who underwent percutaneous thrombectomy between January 2016 and December 2018. We evaluated the demographics, comorbidities, safety outcomes (in-hospital mortality), and health-care resource use (discharge to home, length of stay, and hospital charges) of patients with PE undergoing percutaneous thrombectomy.

RESULTS

Among 1,128,904 patients with a diagnosis of PE between 2016 and 2018, 5,160 patients (0.5%) underwent percutaneous pulmonary artery thrombectomy. When compared with male patients, female patients showed higher procedural bleeding (16.9% vs 11.2%; P < .05), required more blood transfusions (11.9% vs 5.7%; P < .05), and experienced more vascular complications (5.0% vs 1.5%; P < .05). Women experienced higher in-hospital mortality (16.9% vs 9.3%; adjusted OR, 1.9; 95% CI, 1.2-3.0; P = .003) when compared with men. Although length of stay and hospital charges were similar to those of men, women were less likely to be discharged home after surviving hospitalization (47.9% vs 60.3%; adjusted OR, 0.7; 95% CI, 0.50-0.99; P = .04).

INTERPRETATION

In this large nationwide cohort, women with PE who underwent percutaneous thrombectomy showed higher morbidity and in-hospital mortality compared with men.

Assessing Residents' Perceptions of Their Relocation to Long-Term Care: Psychometric Validation of the View of Relocation Scale

OBJECTIVES

Relocation to long-term care is a major challenge for older people. The View of Relocation Scale (VRS) was developed to address the need for a brief instrument to assess residents' perceptions of the relocation.

DESIGN

Secondary analysis of data collected in a cluster randomized trial. The psychometric properties of the VRS examined in this study included factorial structure (using exploratory factor analysis), unidimensionality (Rasch modeling), internal consistency reliability (Kuder-Richardson Formula 20, squared multiple correlations, and item-total correlations), and known groups validity (analysis of variance). The results were used to identify the psychometrically most robust items for inclusion into the final version of the instrument.

SETTING AND PARTICIPANTS

Participants were 202 long-term care residents in Melbourne, Australia (mean age = 85.52 years, standard deviation = 7.33), who had relocated to the facility a mean of 4.4 weeks previously. Residents with moderately severe and severe dementia were excluded.

MEASURES

The VRS was developed following a review of the literature describing residents' views of relocation and was designed for administration shortly after their relocation.

RESULTS

There was support for a 2-factor, 10-item solution, with separate subscales assessing Perceived Control (degree of control in the decision making and planning for the relocation) and Perceived Need (perceived need for the relocation to long-term care). Participants who were admitted directly from hospital reported higher perceived need but lower perceived control than those admitted to the facility from home.

CONCLUSION AND IMPLICATIONS

The VRS can be used to understand the impact of older people's perceptions of relocation to long-term care on their subsequent adjustment and well-being, and to identify those who may benefit from tailored support.

Support for informal carers of older people in the transition to residential aged care: a scoping review protocol

OBJECTIVE

This review aims to identify support delivered to informal carers of older people making the transition into residential aged care, and to examine which specific outcome measures were used in the evaluation of the support provided.

INTRODUCTION

Little support is provided to informal carers of newly admitted aged care residents, both during the admission process and in the subsequent months. Mapping of the support delivered to informal carers of those admitted to a residential aged care facility is needed.

INCLUSION CRITERIA

We will include any form of support (eg, financial, psychological, social) provided to informal carers of people making the transition to residential aged care, from the time a decision is made to proceed with admission, up to 12 months post-admission.

METHODS

We will search peer-reviewed literature in English from 2000 to the present from key databases (ie, MEDLINE, CINAHL, Cochrane Library, JBI Evidence Synthesis, PsycINFO, Embase, and Scopus). Additionally, gray literature will be searched through databases (eg, Google, Google Scholar, BASE, OpenGrey, Grey Literature Report, Informit, MedlinePlus, MedNar, Medscape), government websites, and websites of national organizations that provide support for the care of older people. We will use the JBI approach for search strategy, study selection, and data extraction, and will descriptively map the results using a textual narrative synthesis approach.

Discharge Home From Hospital: How DIRE Can It Be?

Aim: An easy-to-use “DIRE” questionnaire tool was developed to predict an adverse event (AE) within 30 days following discharge from a hospital to the community, among frail elderly individuals aged 65+ years. Methods: Hospital-administered RAI-HC (Residential Assessment Instrument for Home Care) assessment data from 1,433 individuals were used to develop the tool. Results: The DIRE tool outperformed two other instruments that have been used to predict risk in similar populations. Furthermore, the DIRE index was validated on a hold-out sample and in a bootstrapping analysis. Discussion: In addition to its effectiveness in predicting an AE, the added advantages of the DIRE assessment is that only a small amount of data is required and the data are readily available to clinicians at the point of hospital discharge.

New Institutionalization in Long-Term Care After Hospital Discharge to Skilled Nursing Facility

BACKGROUND/OBJECTIVES

Approximately half of individuals newly admitted to long-term care (LTC) nursing homes (NHs) experienced a prior hospitalization followed by discharge to a skilled nursing facility (SNF). The objective was to examine characteristics associated with new institutionalizations of older adults on this care trajectory.

DESIGN

Retrospective cohort study.

SETTING

SNFs and LTC NHs.

PATIENTS

Medicare fee-for-service beneficiaries admitted to 7,442 SNFs in 2013 (N = 597,986).

MEASUREMENTS

We used demographic and clinical characteristics from Medicare data and the Minimum Data Set. We defined "new institutionalization" as LTC NH residence for longer than 90 non-SNF days, starting within 6 months of hospital discharge.

RESULTS

For individuals who survived 6 months after hospital discharge, the overall rate of new LTC institutionalizations was 10.0% (N = 59,736). Older age, white race, being unmarried, Medicaid eligibility, higher income, more comorbidities, cognitive impairment, depression, functional limitations, hallucinations and delusions, aggressive behavior, incontinence, and pressure ulcers were associated with higher adjusted odds of new LTC institutionalization. In analyses stratified according to race and ethnicity, higher income was associated with lower odds of LTC institutionalization for whites (odds ratio (OR) = 0.92, 95% confidence interval (CI) = 0.89-0.96) and greater odds for blacks (OR = 1.40, 95% CI = 1.27-1.55) and Hispanics (OR = 1.44, 95% CI = 1.25-1.66). Moderate or severe depression, functional limitations, hallucinations and delusions, aggressive behavior, and being unmarried were stronger risk factors for LTC for cognitively intact individuals than for those with moderate to severe cognitive impairment. Being unmarried and having more comorbidities were stronger predictors in those aged 66 to 70 than in those aged 81 to 85 and 91 and older.

CONCLUSION

Associations between risk factors and new LTC institutionalizations varied according to race and ethnicity, age, and level of cognitive function. Programs that target older adults at greater risk may be an effective strategy for reducing new institutionalizations and fostering aging in place.

Management of Relocation in Cognitively Intact Older Adults

Relocation, a major life transition that can affect health positively and negatively, is moving from one permanent home to another. Many older adults will relocate at some time during their life. Relocation is also a complex process that requires careful consideration and planning before the move (i.e., pre-location) and adjustment to the new home after the move (i.e., post-relocation). The current article is a summary of content based on a comprehensive evidence-based practice guideline focused on management of relocation in cognitively intact older adults. The guideline was designed to be used across diverse settings by nurses and other providers. Pre-relocation guidelines include assessment for the need for relocation, interventions prior to moving, and outcomes for evaluation of the pre-relocation process. For post-relocation, content focuses on assessment of risks for not adjusting after the move as well as intervention guidelines to promote adjustment and outcomes for evaluation. Implications include advocacy for older adults by using the guideline, disseminating it, and conducting future research. [Journal of Gerontological Nursing, 42(11), 14-23.].

Are health assets associated with improved outcomes for hospitalised older adults? A systematic review

OBJECTIVE

Health assets are protective factors that support health and wellbeing, rather than risk factors that are associated with disease. This concept was developed in the community setting. In hospitalised older adults, the dominant approach has been to identify risk factors, with little examination of health assets. The purpose of this systematic review was to determine whether, in hospitalised older people, individual health assets decrease the risk of post hospital mortality, functional decline, new need for residential care, readmission or longer length of stay.

METHODS

MEDLINE, EMBASE, CINAHL and PsycINFO were searched to identify studies examining outcomes for hospitalised older adults. Included studies examined at least one potential individual health asset, which was a psychosocial characteristic or health characteristic. Study quality was assessed, and findings are narratively described.

RESULTS

Nine prospective cohort and two retrospective cohort studies were identified. subjective, functional and biological health assets were identified. Health assets were associated with decreased risk of post-hospital mortality, functional decline, new need for residential care and readmission.

CONCLUSION

The complex interplay between health status and psychological and social factors is incompletely understood. Health assets are associated with improved outcomes for hospitalised older adults. The small number of studies suitable for inclusion indicates the need for further research in this area.

Evaluating Siebens Domain Management Model for inpatient rehabilitation to increase functional independence and discharge rate to home in geriatric patients

OBJECTIVE

To evaluate the Siebens Domain Management Model (SDMM) for geriatric inpatient rehabilitation (IR) to increase functional independence and dispositions to home.

DESIGN

Before and after study.

SETTING

IR facility.

PARTICIPANTS

During 2010 (preintervention), 429 patients aged ≥75 years who were on average admitted to IR 8.2 days postacute care, and during 2012 (postintervention), 524 patients aged ≥75 years who were on average admitted to IR 5.5 days postacute care. Case-mix group (CMG) comorbidity tier severity, preadmission living setting, and living support were similar in both groups.

INTERVENTION

The SDMM involving weekly adjustments of IR care focused on potential barriers to discharge home.

MAIN OUTCOME MEASURES

FIM efficiency, length of stay (LOS), and disposition rates to community/home, acute care, and long-term care (LTC) to compare pre-/postintervention facility data and comparison of facility to national CMG-adjusted data from the Uniform Data System for Medical Rehabilitation for both years (2010/2012).

RESULTS

Pre-/postintervention group admission FIM scores were similar (t=2.96, P<.003), but the preintervention group had on average 2.6 days greater LOS during IR and greater time to onset of IR (8.2 vs 5.5d) from acute care. Preintervention FIM efficiency was 2.1, whereas postintervention FIM efficiency was 2.76, a significant difference (t=4.1, P<.0001). There were significantly more discharges to the community in the postintervention group (74.4%) than the preintervention group (58.5%, χ(2)=26.2, P<.0001). There were significantly fewer patients discharged to LTC in the postintervention group (χ(2)=30.47, P<.0001). The preintervention group did not significantly differ from the 2010 national data, but the postintervention group significantly differed from the 2012 national data for both greater FIM efficiency (t=-5.5, P<.0001) and greater discharge to community (χ(2)=34, P<.0001). LOS decreased by 2.6 days in the postintervention group compared with the preintervention group, whereas LOS decreased by only 0.6 days nationally from 2010 to 2012, a significant difference with postintervention LOS lower than the national data (t=31.1, P<.0001).

CONCLUSIONS

Use of the SDMM during IR in geriatric patients is associated with increased functional independence and discharges to home/community and reduced institutionalization.

Evaluating use of the Siebens Domain Management Model during inpatient rehabilitation to increase functional independence and discharge rate to home in stroke patients

OBJECTIVE

To evaluate use of the Siebens Domain Management Model (SDMM) during stroke inpatient rehabilitation (IR) to increase functional independence and rate of discharge to home.

DESIGN

Before and after study.

SETTING

IR facility.

PARTICIPANTS

Before the intervention: 154 patients with ischemic/hemorrhagic strokes who were admitted to an IR facility in 2010; on average, they were admitted 9.1 days after receiving acute care. After the intervention: 151 patients with ischemic/hemorrhagic strokes who were admitted to an IR facility in 2012; on average they were admitted 7.3 days after receiving acute care. The comorbidity tier severity and prestroke living setting and living support appeared to be similar in both the preintervention and postintervention groups.

INTERVENTION

Use of the SDMM involving weekly adjustments of IR care focused on potential barriers to discharge home including medical/surgical issues, cognitive/emotional coping issues, physical function, and living environment/community re-entry needs.

MAIN OUTCOME MEASURES

Use of Functional Independence Measure (FIM) score change during IR length of stay (LOS; FIM-LOS efficiency) and rates of discharge to community/home, acute care, and long-term care (LTC) to compare 2010/preintervention data with postintervention data from 2012, along with comparison of facility data to national aggregate data from the Uniform Data System for Medical Rehabilitation (UDSMR) for both years.

RESULTS

Preintervention 2010 FIM-LOS efficiency was 1.44 compared with a 2012 postintervention FIM-LOS efficiency of 2.24, which was significant (t = 4.3; P < .0001). Comparison of the UDSMR 2012 national FIM-LOS efficiency score (1.72) to the 2012 postintervention score of 2.24 reached significance (t = 2.6; P < .01). In addition, a significant difference was found between groups for discharge location: In the preintervention group, 57.8% were discharged to home/community, 14.9% to LTC, and 27.3% back to acute care compared with the postintervention group, in which 81.2% were discharged to home/community, 9.4% to LTC, and 9.4% back to acute care (χ(2) = 8.98; P < .001). Also significant was comparison between the 2012 postintervention group and the 2012 national UDSMR data for the same 3 discharge locations (χ(2) = 3.94; P < .05). Comparison of 2010 to 2012 facility data then shows a 23.4% increase in discharge to the community compared with an increase of 5.8% for the UDSMR 2010 to 2012 data, representing a community discharge rate that is 4 times greater for the 2012 facility postintervention group (χ(2) = 83.596; P < .0001).

CONCLUSIONS

Use of the SDMM during stroke IR may convey improvement in functional independence and is associated with an increased discharge rate to home/community and a reduction in institutionalization and acute-care transfers.

The effects of shared situational awareness on functional and hospital outcomes of hospitalized older adults with heart failure

BACKGROUND

Functional decline of hospitalized older adults is common and triggers health care expenditures. Physical therapy can retard the functional decline that occurs during hospitalization. This study aims to examine whether shared situational awareness (SSA) intervention may enhance the benefits of physical therapy for hospitalized older persons with a common diagnosis, heart failure.

METHOD

An SSA intervention that involved daily multidisciplinary meetings was applied to the care of functionally declining older adults admitted to the medicine floor for heart failure. Covariates were matched between the intervention group (n=473) and control group (n=475). Both intervention and control groups received physical therapy for ≥0.5 hours per day. The following three outcomes were compared between groups: 1) disability, 2) transition to skilled nursing facility (SNF, post-acute care setting), and 3) 30-day readmission rate.

RESULTS

Disability was lower in the intervention group (28%) than in the control group (37%) (relative risk [RR] =0.74; 95% confidence interval [CI], 0.35-0.97; P=0.026), and transition to SNF was lower in the intervention group (22%) than in the control group (30%) (RR =0.77; 95% CI, 0.39-0.98; P=0.032). The 30-day readmission rate did not significantly differ between the two groups.

CONCLUSION

SSA intervention enhanced the benefits of physical therapy for functionally declining older adults. When applied to older adults with heart failure in the form of daily multidisciplinary meetings, SSA intervention improved functional outcomes and reduced transfer to SNFs after hospitalization.

Predictors of Hospital Discharge to an Extended Care Facility after Major General Thoracic Surgery

Failure to anticipate the need to discharge patients to rehabilitation centers and skilled nursing facilities results in expensive delays in the discharge of patients after surgery. Early identification of patients at high risk for discharge to these extended care facilities could mitigate these delays and expenditures. The purpose of this study was to identify preoperative patient factors associated with discharge to extended care facilities after major general thoracic surgery. Discharge records were identified for all patients undergoing major general thoracic surgery admitted to a university hospital between January 2006 and May 2009 who had a stay of longer than one day. The following risk factors were selected a priori based on clinical judgment: age, preoperative albumin, pre-operative Zubrod score, history of peripheral vascular disease, and use of home oxygen. Multiple logistic regression analysis was used to estimate the statistical significance and magnitude of risk associated with each predictor of patient discharge to extended care facilities. Of the 1646 patients identified, 68 (4.1%) were discharged to extended care facilities. Hospital length of stay was on average six days longer for patients discharged to these facilities than for patients discharged home ( P < 0.0001). Multivariate analysis demonstrated that advanced age, lower preoperative albumin, and increased preoperative Zubrod score were statistically significant predictors of discharge to extended care facilities. Age, preoperative nutritional status, and functional status are strong predictors of patient discharge to extended care facilities. Early identification of these patients may improve patient discharge planning and reduce hospital length of stay after major thoracic surgery.

A Model of Risk Reduction for Older Adults Vulnerable to Nursing Home Placement

Because of the cost of nursing home care and desire of older adults to stay in their homes, it is important for health care providers to understand the factors that place older adults at risk for nursing home placement. This integrative review of 12 years of research, as published in 148 articles, explores the risk factors for nursing home placement of older adults. Using the framework of the vulnerable populations conceptual model developed by Flaskerud and Winslow (1998), we explored factors related to resource availability, relative risks, and health status. Important factors include socioeconomic status, having a caregiver, the availability and use of home- and community-based support services, race, acute illness particularly if hospitalization is required, medications, dementia, multiple chronic conditions, functional disability, and falls. Few intervention studies were identified. Development of evidence-based interventions and creation of policies to address modifiable risk factors are important next steps.

Utilization of long-term care services under the public long-term care insurance program in Korea: Implications of a subsidy policy

OBJECTIVES

South Korea introduced public long-term care insurance (LTCI) in 2008. This study examined the patterns of and factors associated with public long-term care (LTC) utilization among older LTCI beneficiaries in Korea, with special attention to the policy for subsidizing the co-payments of lower income populations.

METHODS

Using a 5% national representative sample of 280,290 older people aged 65 or older obtained from the 2010 national LTCI claims database, we examined socio-demographic and health factors associated with service utilization decisions, service type chosen, and the intensity of service use.

RESULTS

About 5.48% of older adults in 2010 utilized the LTC provided under the Korean public LTCI, among which about 26.1% received a subsidy. Compared to their counterparts, the subsidized users were more likely to be low-income, female, and living alone. They were more likely to choose institutionalized care and spend to their monthly benefit limit while paying a lower co-payment. The factors associated with pattern and intensity of LTC utilization were not the same between subsidized and non-subsidized users.

CONCLUSION

The findings imply the subsidy policy promotes equity of access to public LTC services. Further evaluation is necessary on the impact of the policy on the effectiveness of LTC utilization by socially marginalized populations.

What is different about living alone with cancer in older age? A qualitative study of experiences and preferences for care

Background

Increasing numbers of older patients with advanced cancer live alone but there is little research on how well health services meet their needs. The aim of this study was to compare the experiences and future preferences for care between two groups of older people with cancer in their last year of life; those who live alone, and those who live with co-resident carers.

Methods

In-depth qualitative interviews were conducted with 32 people aged between 70 and 95 years who were living with cancer. They were recruited from general practices and hospice day care, when the responsible health professional answered no to the question, of whether they would be surprised if the patient died within twelve months. Twenty participants lived alone. Interviews were recorded and transcribed and the data analysed using a Framework approach, focussing on the differences and commonalities between the two groups.

Results

Many experiences were common to all participants, but had broader consequences for people who lived alone. Five themes are presented from the data: a perception that it is a disadvantage to live alone as a patient, the importance of relational continuity with health professionals, informal appraisal of care, place of care and future plans. People who lived alone perceived emotional and practical barriers to accessing care, and many shared an anxiety that they would have to move into a care home. Participants were concerned with remaining life, and all who lived alone had made plans for death but not for dying. Uncertainty of timescales and a desire to wait until they knew that death was imminent were some of the reasons given for not planning for future care needs.

Conclusions

Older people who live alone with cancer have emotional and practical concerns that are overlooked by their professional carers. Discussion and planning for the future, along with continuity in primary care may hold the key to enhancing end-of-life care for this group of patients.

Intensified rehabilitation therapy and transitions to skilled nursing facilities in community-living seniors with acute medical illnesses

AIM

To examine whether rehabilitation therapy type would be associated with transitions to skilled nursing facilities (SNF) in community-living seniors with acute medical illnesses.

METHODS

Using administrative and clinical data, multivariate regression analysis examined the relationship between the extent of rehabilitation therapy and transitions to SNF in all participants, as well as participants by physical function at admission.

RESULTS

In all participants (n=929), the intensified rehabilitation therapy was associated with a lower probability of transitions to SNF (14% vs 21%; odds ratio [OR] 0.59; 95% confidence intervals [CI] 0.22-0.96; P=0.02). In participants with mild physical limitations (n=270), less frequent transitions to SNF occurred when patients received intensified rehabilitation therapy [16% vs 23%; OR 0.46; 95% CI 0.17-0.94; P=0.01]. In participants with moderate to severe physical limitations (n=265), the decreased frequency of transitions to SNF associated with rehabilitation therapy became more pronounced (18% vs 28%; OR 0.34; 95% CI 0.07-0.89; P=0.004). By contrast, in participants without physical limitation (n=394), the number of transitions to SNF did not change significantly when they received intensified rehabilitation therapy (P=0.53).

CONCLUSIONS

We found a significant relationship between intensified rehabilitation therapy and the decrease of transitions to SNF in community-living seniors with acute medical illness. The magnitude of this relationship increased in participants with more physical limitations, but not in participants without physical limitations at admission.

Delirium and transition to a nursing home of hospitalized older adults: a controlled trial of assessing the interdisciplinary team-based "geriatric" care and care coordination by non-geriatrics specialist physicians

AIM

To examine whether a team-based inpatient "geriatric" care model provided by non-geriatrics specialist physicians was associated with changes in the occurrence of delirium and transition to a nursing home.

METHODS

We carried out an intervention (interdisciplinary; ITD group) control (usual care group) study comparing the outcomes of hospitalized older adults cared for by non-geriatrics specialist physicians. Compared with the usual care group, the ITD intervention group provided additional value: geriatric care and care coordination by leading daily ITD team meetings.

RESULTS

After adjusting for patient demographics and clinical characteristics, the probability of transition to a nursing home in the ITD intervention group was significantly lower (odds ratio 0.52; 95% confidence intervals, 0.16-0.94; P = 0.008) than that in the usual care group. However, there was no significant difference in the predicted probabilities of delirium between the ITD intervention and usual care groups.

CONCLUSION

As compared with the usual care group, a significantly lower probability of transition to a nursing home was observed in the ITD intervention group, but the probabilities of delirium between the ITD intervention and usual care groups did not differ significantly.

Risk factors associated with epidural use

Background

Identify variables associated with intrapartum epidural use.

Methods

Odds ratios were calculated to quantify associations between selected variables and epidural use using a population-based case-control study of Washington State birth certificate data from 2009.

Results

Non-Whites had 10 - 45% lower odds of epidural use relative to Whites. Foreign-born women had 25 - 45% lower odds of epidural use compared to their US-born counterparts, except for Asians. Women who smoked or induced labor had higher roughly 2-fold higher odds of epidural use compared with non-smokers or women giving birth spontaneously, respectively. Women without a high school diploma or equivalent had lower odds of epidural use relative to those who graduated. Delivering at perinatal units, rural hospitals, or non-profit hospitals had ~50% lower odds of epidural use compared with secondary/teritiary perinatal units, urban hospitals or for-profit hospitals, respectively. 

Conclusion

Several individual and health service-related variables were associated with epidural use. These findings elucidate the clinical relevance of epidural use, and dispariaties in its utilization and in quality of care during delivery.

Keywords

Epidural use; Foreign birth; Labor; Racial disparities