Socioeconomic and Geographic Disparities in Accessing Nursing Homes With High Star Ratings

Star Ratings in Long-Term Care Facilities in Australia: Facility Characteristics Associated with High Ratings and Changes in Ratings Over Time

OBJECTIVES

A Star Rating system (1 to 5 stars) of long-term care facilities in Australia is based on 4 sub-categories: compliance, quality measures, residents' experience, and staffing. The objectives were to examine associations between facility characteristics and the odds of receiving a 4- or 5-star rating, and changes in ratings between the earliest reporting period (October-December 2022) to the most recent (April-June 2023).

DESIGN

Cross-sectional, ecological study, with an additional longitudinal component.

SETTING

Long-term care facilities in Australia.

METHODS

Associations between facility characteristics and the odds of receiving a 4- or 5-star rating were examined using a multiple logistic regression model. Average changes in overall star rating and each sub-category weighted by fractional contribution to overall star rating were estimated.

RESULTS

Of 2476 facilities, 53.7% received a 4- or 5-star rating, 44.1% a 3-star rating, and 2.1% a 1- or 2-star rating in the April-June 2023 reporting period. Facility characteristics associated with higher odds of 4- or 5-star ratings included small (≤60 residents) and medium-size (61-100 residents) (odds ratios, 3.16; 95% CI, 2.51-3.98 and 1.72; 95% CI, 1.38-2.13, respectively), and Queensland location compared with New South Wales (2.42; 95% CI, 1.87-3.14). Facilities in socioeconomically disadvantaged areas (0.45; 95% CI, 0.33-0.62) and for-profit (0.12; 95% CI, 0.07-0.22) or not-for-profit facilities (0.16; 95% CI, 0.09-0.29) compared with government-operated were associated with lower odds of 4- or 5-star ratings. Between the 2 reporting periods, 25.1% of facilities' star ratings increased and 10.2% decreased (average change 0.156). Residents' experience, compliance, and staffing had the largest weighted average sub-category rating changes (0.051, 0.042, and 0.042, respectively).

CONCLUSIONS

Smaller size, government ownership, and location in socioeconomically advantaged areas were associated with higher odds of 4- or 5-star ratings in long-term care facilities. Average star ratings increased over time but increases and decreases in overall and sub-category ratings were observed.

Exploring Place of Death among Individuals with Huntington's Disease in the United States

OBJECTIVES

To describe trends and identify factors associated with place of death among individuals with Huntington's disease (HD).

DESIGN

Retrospective cohort of deceased individuals with HD from the Centers for Disease Control and Prevention's National Center for Health Statistics.

SETTING AND PARTICIPANTS

A total of 13,350 individuals with HD who died in the United States between 2009 and 2019.

METHODS

We analyzed place of death, categorized as long-term care (LTC) facility, home, hospital, hospice facility, and other locations. Trends in the places of death from 2009 to 2019 were assessed using linear regression models. Multivariate logistic regression models were used to identify sociodemographic factors associated with place of death.

RESULTS

From 2009 to 2019, the greatest proportion of deaths occurred in LTC facilities (48.4%). There was a significantly decreasing trend in the proportion of deaths occurring in LTC facilities (53.5%-43.9%, P < .001). A greater proportion of deaths in rural areas occurred in LTC facilities compared with all other locations (P < .001 for all comparisons). In the multivariate model, aged younger than 44 years, Black race, Hispanic ethnicity, some college education or greater, and being married were associated with significantly lower odds of dying in a LTC facility compared with home.

CONCLUSIONS AND IMPLICATIONS

Despite a decreasing trend, LTC facilities remain a cornerstone of support for individuals with HD, particularly in rural areas. These results suggest multiple avenues for research to improve accessibility and quality of care for individuals with late stages of HD. Future studies are needed to further understand the impact of rurality and lack of support in the home on the accessibility and quality of LTC and hospice care for individuals with HD. These results may also help inform interventions focused on training and staff education within LTC and hospice facilities to better manage HD progression and symptoms.

C. auris and neighborhood socioeconomic vulnerability in the state of Maryland from 2019 to 2022

BACKGROUND

Candida auris is an emerging fungal pathogen increasingly recognized as a cause of healthcare-associated infections including outbreaks.

METHODS

We performed a mixed-methods study to characterize the emergence of C. auris in the state of Maryland from 2019 to 2022, with a focus on socioeconomic vulnerability and infection prevention opportunities. We describe all case-patients of C. auris among Maryland residents from June 2019 to December 2021 detected by Maryland Department of Health. We compared neighborhood socioeconomic characteristics of skilled nursing facilities (SNFs) with and without C. auris transmission outbreaks using both the social vulnerability index (SVI) and the area deprivation index (ADI). The SVI and the ADI were obtained at the state level, with an SVI ≥ 75th percentile or an ADI ≥ 80th percentile considered severely disadvantaged. We summarized infection control assessments at SNFs with outbreaks using a qualitative analysis.

RESULTS

A total of 140 individuals tested positive for C. auris in the study period in Maryland; 46 (33%) had a positive clinical culture. Sixty (43%) were associated with a SNF, 37 (26%) were ventilated, and 87 (62%) had a documented wound. Separate facility-level neighborhood analysis showed SNFs with likely C. auris transmission were disproportionately located in neighborhoods in the top quartile of deprivation by the SVI, characterized by low socioeconomic status and high proportion of racial/ethnic minorities. Multiple infection control deficiencies were noted at these SNFs.

CONCLUSION

Neighborhood socioeconomic vulnerability may contribute to the emergence and transmission of C. auris in a community.

Geospatial Distribution of Racial Disparities in Influenza Vaccination in Nursing Homes

OBJECTIVES

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

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS AND IMPLICATIONS

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

Older Adults' Unmet Needs at the End of Life: A Cross-Country Comparison of the United States and England

Objectives: This study aimed to compare the end-of-life (EOL) experiences in concentration with place of death, for older adults in the U.S. and England. Methods: Weighted comparative analysis was conducted using harmonized Health and Retirement Study and English Longitudinal Study of Ageing datasets covering the period of 2006-2012. Results: At the EOL, more older adults in the U.S. (64.14%) than in England (54.09%) had unmet needs (I/ADLs). Home was the main place of death in the U.S. (47.34%), while it was the hospital in England (58.01%). Gender, marital status, income, place of death, previous hospitalization, memory-related diseases, self-rated health, and chronic diseases were linked to unmet needs in both countries. Discussion: These findings challenge the existing assumptions about EOL experiences and place of death outcomes, emphasizing the significance of developing integrated care models to bolster support for essential daily activities of older adults at the EOL.

Changes in Nursing Home Use Following Medicaid-Supported Expanded Access to Home- and Community-Based Services for Older Adults With Dementia

Importance

New York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care.

Objective

To evaluate changes in nursing home use among older adults with dementia following MLTC implementation.

Design, Setting, and Participants

This cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019.

Exposure

Mandatory MLTC enrollment.

Main Outcomes and Measures

Longitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators.

Results

This sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year).

Conclusions and Relevance

The findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.

Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated.

CONTEXT

Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors.

METHODS

We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design.

FINDINGS

After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use.

CONCLUSIONS

Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

Severe neighborhood deprivation and nursing home staffing in the United States

BACKGROUND

Low nursing home staffing in the United States is a growing safety concern. Socioeconomic deprivation in the local areas surrounding a nursing home may be a barrier to improving staffing rates but has been poorly studied. Thus, the objective of this paper was to assess the relationship between neighborhood deprivation and nursing home staffing in the United States.

METHODS

This cross-sectional study used 2018 daily payroll-based staffing records and address data for 12,609 nursing homes in the United States linked with resident assessment data. Our primary exposure of interest was severe economic deprivation at the census block group (neighborhood) level, defined as an area deprivation index score ≥85/100. The primary outcome was hours worked per resident-day among nursing home employees providing direct resident care. Marginal linear regression models and generalized estimating equations with robust sandwich-type standard errors were used to estimate associations between severe neighborhood deprivation and staffing rates.

RESULTS

Compared to less deprived neighborhoods, unadjusted staffing rates in facilities located within severely deprived neighborhoods were 38% lower for physical and occupational therapists, 30% lower for registered nurses (RNs), and 5% lower for certified nursing assistants. No disparities in licensed practical nurse (LPN) staffing were observed. In models with state-level and rurality fixed effects and clustered on the county, a similar pattern of disparities was observed. Specifically, RN staffing per 100 resident-days was significantly lower in facilities located within severely deprived neighborhoods as compared to those in less deprived areas (mean difference: 5.6 fewer hours, 95% confidence interval [CI] 4.2-6.9). Disparities of lower magnitude were observed for other clinical disciplines except for LPNs.

CONCLUSIONS

Significant staffing disparities were observed within facilities located in severely deprived neighborhoods. Targeted interventions, including workforce recruitment and retention efforts, may be needed to improve staffing levels for nursing homes in deprived neighborhoods.

Factors Differentiating Nursing Homes With Strong Resident Safety Climate: A Qualitative Study of Leadership and Staff Perspectives

The current qualitative study assessed leadership and staff perceptions related to resident safety at Department of Veterans Affairs (VA) nursing homes with a range of safety climates. We recruited a purposive sample of six VA nursing homes from geographically diverse regions of the United States and with diverse overall safety climate ratings. We conducted semi-structured phone interviews with 43 senior and middle level nursing home leaders and frontline providers (medical and nursing). We performed a thematic analysis of interview data to assess participant perceptions of factors that influence resident safety at higher and lower safety climate sites. Analyses identified two factors that differentiated VA nursing homes with high safety climate ratings from those with medium or low ratings: (1) communication about resident safety, particularly the important role of accessibility of physicians and managers; and (2) leadership support for and responsiveness to resident safety issues raised by frontline staff. Findings from high safety climate nursing homes underscore the importance of leadership accessibility, communication, support, and follow through regarding resident safety concerns. These results may provide a basis for designing safety climate interventions, such as those designed to improve communication, teamwork, and quality improvement structures and processes. [Journal of Gerontological Nursing, 49(2), 13-17.].

Examining Regional Differences in Nursing Home Palliative Care for Black and Hispanic Residents

Background: Approximately one-quarter of all deaths in the United States occur in nursing homes (NHs). Palliative care has the potential to improve NH end-of-life care, but more information is needed on the provision of palliative care in NHs serving Black and Hispanic residents. Objective: To determine whether palliative care services in United States NHs are associated with differences in the concentrations of Black and Hispanic residents, respectively, and the impact by region. Design: We conducted a cross-sectional analysis. The outcome was NH palliative care services (measured by an earlier national survey); total scores ranged from 0 to 100 (higher scores indicated more services). Other data included the Minimum Data Set and administrative data. The independent variables were concentration of Black and Hispanic residents (i.e., <3%, 3-10%, >10%), respectively, and models were stratified by region (i.e., Northeast, Midwest, South and West). We compared unadjusted, weighted mean palliative care services by the concentration of Black and Hispanic residents and computed NH-level multivariable linear regressions. Setting/Subjects: Eight hundred sixty-nine (weighted n = 15,020) NHs across the United States. Results: Multivariable analyses showed fewer palliative care services provided in NHs with greater concentrations of Black and Hispanic residents. Fewer palliative care services were reported in NHs in the Northeast, for which >10% of the resident population was Black, and NHs in the West for which >10% was Hispanic versus NHs with <3% of the population being Black and Hispanic (-13.7; p < 0.001 and -9.3; p < 0.05, respectively). Conclusion: We observed differences in NH palliative care by region and with greater concentration of Black and Hispanic residents. Our findings suggest that greater investment in NH palliative care services may be an important strategy to advance health equity in end-of-life care for Black and Hispanic residents.

Southeastern United States Predictors of COVID-19 in Nursing Homes

This study's aim was to determine nursing home (NH) and county-level predictors of COVID-19 outbreaks in nursing homes (NHs) in the southeastern region of the United States across three time periods. NH-level data compiled from census data and from NH compare and NH COVID-19 infection datasets provided by the Center for Medicare and Medicaid Services cover 2951 NHs located in 836 counties in nine states. A generalized linear mixed-effect model with a random effect was applied to significant factors identified in the final stepwise regression. County-level COVID-19 estimates and NHs with more certified beds were predictors of COVID-19 outbreaks in NHs across all time periods. Predictors of NH cases varied across the time periods with fewer community and NH variables predicting COVID-19 in NH during the late period. Future research should investigate predictors of COVID-19 in NH in other regions of the US from the early periods through March 2021.

Quality of Nursing Homes Admitting Working-Age Adults With Serious Mental Illness

OBJECTIVE

This cross-sectional study examined the association between nursing home quality and admission of working-age persons (ages 22-64 years) with serious mental illness.

METHODS

The study used 2015 national Minimum Data Set 3.0 and Nursing Home Compare (NHC) data. A logistic mixed-effects model estimated the likelihood (adjusted odds ratios [AORs] and 95% confidence intervals [CIs]) of a working-age nursing home resident having serious mental illness, by NHC health inspection quality rating. The variance partition coefficient (VPC) was calculated to quantify the variation in serious mental illness attributable to nursing home characteristics. Measures included serious mental illness (i.e., schizophrenia, bipolar disorder, and other psychotic disorders), health inspection quality rating (ranging from one star, below average, to five stars, above average), and other sociodemographic and clinical covariates.

RESULTS

Of the 343,783 working-age adults newly admitted to a nursing home in 2015 (N=14,307 facilities), 15.5% had active serious mental illness. The odds of a working-age resident having serious mental illness was lowest among nursing homes of above-average quality, compared with nursing homes of below-average quality (five-star vs. one-star facility, AOR=0.78, 95% CI=0.73-0.84). The calculated VPC from the full model was 0.11.

CONCLUSIONS

These findings indicate an association between below-average nursing homes and admission of working-age persons with serious mental illness, suggesting that persons with serious mental illness may experience inequitable access to nursing homes of above-average quality. Access to alternatives to care, integration of mental health services in the community, and improving mental health care in nursing homes may help address this disparity.

Structural Racism, Place, and COVID-19: A Narrative Review Describing How We Prepare for an Endemic COVID-19 Future

Background:

Place is a social determinant of health, as recently evidenced by COVID-19. Previous literature surrounding health disparities in the United States often fails to acknowledge the role of structural racism on place-based health disparities for historically marginalized communities (i.e., Black and African American communities, Hispanic/Latinx communities, Indigenous communities [i.e., First Nations, Native American, Alaskan Native, and Native Hawaiian], and Pacific Islanders). This narrative review summarizes the intersection between structural racism and place as contributors to COVID-19 health disparities.

Methods:

This narrative review accounts for the unique place-based health care experiences influenced by structural racism, including health systems and services and physical environment. We searched online databases for peer-reviewed and governmental sources, published in English between 2000 and 2021, related to place-based U.S. health inequities in historically marginalized communities. We then narrate the link between the historical trajectory of structural racism and current COVID-19 health outcomes for historically marginalized communities.

Results:

Structural racism has infrequently been named as a contributor to place as a social determinant of health. This narrative review details how place is intricately intertwined with the results of structural racism, focusing on one's access to health systems and services and physical environment, including the outdoor air and drinking water. The role of place, health disparities, and structural racism has been starkly displayed during the COVID-19 pandemic, where historically marginalized communities have been subject to greater rates of COVID-19 incidence and mortality.

Conclusion:

As COVID-19 becomes endemic, it is crucial to understand how place-based inequities and structural racism contributed to the COVID-19 racial disparities in incidence and mortality. Addressing structurally racist place-based health inequities through anti-racist policy strategies is one way to move the United States toward achieving health equity.

Abuse and Neglect in Nursing Homes: The Role of Serious Mental Illness

BACKGROUND AND OBJECTIVES

Nursing homes (NH) are serving a large number of residents with serious mental illness (SMI). We analyze the highest ("High-SMI") quartile of NHs based on the proportion of residents with SMI and compare NHs on health deficiencies and the incidence of deficiencies given for resident abuse, neglect, and involuntary seclusion.

RESEARCH DESIGN AND METHODS

We used national Certification and Survey Provider Enhanced Reports (CASPER) data for all freestanding certified NHs in the continental United States from 2014 to 2017 (14,698 NHs; 41,717 recertification inspections; 246,528 deficiencies). Differences in the number of deficiencies, a weighted deficiency score, the deficiency grade, and the facility characteristics associated with deficiencies for abuse, neglect, and involuntary seclusion were examined in High-SMI. Incidence rate ratios (IRR) and odds ratios (OR) were reported with 95% confidence intervals.

RESULTS

High-SMI NHs did not receive more deficiencies or a greater weighted deficiency score per recertification inspection. Deficiencies given to High-SMI NHs were associated with a wider scope, especially Pattern (IRR:1.03;[1.00, 1.07]) and Widespread (IRR:1.07;[1.02, 1.11]). High-SMI NHs were more likely to be cited for resident abuse and neglect (OR:1.49;[1.23, 1.81]) and the policies to prohibit and monitor for abuse and neglect (OR:1.18;[1.08, 1.30]) in comparison to all other NHs.

DISCUSSION AND IMPLICATIONS

Although resident abuse, neglect, and involuntary seclusion are rarely cited, these deficiencies are disproportionately found in High-SMI NHs. Further work is needed to disentangle the antecedents to potential resident abuse and neglect in those with mental healthcare needs.

Decomposing Differences in Risk-Adjusted Rates of Emergency Department Visits Between Micropolitan and Urban Nursing Homes

OBJECTIVES

Nursing homes (NHs) in micropolitan areas are reported to have different facility and market factors than urban NHs, but how these factors contribute to differences in emergency department (ED) visits remains unknown. This study examined and quantified sources of micropolitan-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED (PAED) visits of long-stay residents.

DESIGN

The 2011-2013 national Medicare claims and NH Minimum Data Set (MDS) 3.0 were analyzed. We implemented generalized estimating equation models to examine micropolitan-urban differences in ED rates and Blinder-Oaxaca decompositions to quantify the contributions of NH and market factors.

SETTING AND PARTICIPANTS

The study cohort included 12,883 unique privately owned, freestanding NHs from urban and micropolitan areas.

MEASURES

Quarterly risk-adjusted rates of any ED visits, outpatient ED visits, and PAED visits were calculated from Medicare claims and MDS. NH and market characteristics were extracted from the Certification And Survey Provider Enhanced Reporting and Area Health Resources File.

RESULTS

Over the study period, risk-adjusted rates averaged 10.2%, 3.4%, and 3.3% for any ED, outpatient ED, and PAED visits, respectively. Compared with urban NHs, micropolitan NHs reported similar rates of any ED, but significantly higher rates of outpatient ED and PAED (β = 0.20% and 0.27%; both P < .05). Observable differences in NH characteristics (eg, number of beds, percentage Medicare or Medicaid residents, and employment of nurse practitioners and physician assistants) explained more than 20% of the micropolitan-urban differences in rates of outpatient ED and PAED visits; market factors (mainly Medicare Advantage penetration) explained about 46% of the differences in rates of outpatient ED visits.

CONCLUSIONS AND IMPLICATIONS

Compared with urban NHs, micropolitan NHs tend to utilize more avoidable emergency care that can be partially explained by facility size, payer mix, use of nurse practitioners and physician assistants, and market structure.

The disparities in health insurance ownership of hospital-based birth deliveries in eastern Indonesia

BACKGROUND

Development in Eastern Indonesia tends to be left behind compared to other Indonesian regions, including development in the health sector. The study aimed at analyzing the health insurance ownership disparities in hospital delivery in Eastern Indonesia.

METHODS

The study draws on secondary data from the 2017 Indonesia Demographic and Health Survey. The study population was women aged 15-49 years who had given birth in the last five years in Eastern Indonesia. The study analyzes a weighted sample size of 2299 respondents. The study employed hospital-based birth delivery as a dependent variable. Apart from health insurance ownership, other variables analyzed as independent variables are province, residence type, age group, marital status, education level, employment status, parity, and wealth status. The final stage analysis used binary logistic regression.

RESULTS

The results showed that insured women were 1.426 times more likely than uninsured women to undergo hospital delivery (AOR 1.426; 95% CI 1.426-1.427). This analysis indicates that having health insurance is a protective factor for women in Eastern Indonesia for hospital delivery. There is still a disparity between insured and uninsured women in hospital-based birth deliveries in eastern Indonesia. Insured women are nearly one and a half times more likely than uninsured women to give birth in a hospital.

CONCLUSION

The study concludes that there are health insurance ownership disparities for hospital delivery in eastern Indonesia. Insured women have a better chance than uninsured women for hospital delivery.

Nursing Home Compare Star Rating and Daily Direct-Care Nurse Staffing During Hurricane Irma

OBJECTIVES

Nursing homes (NHs) are affected by major hurricanes and other natural disasters. To mitigate adverse effects of a major hurricane, NHs often increase their direct-care nurse staffing levels to meet the needs of their residents. However, the quality rating of the NH may affect the resources available to obtain and retain staff. This data brief provides estimates of direct-care nurse staffing levels by quality star rating during Hurricane Irma.

DESIGN

Retrospective cohort study from September 3, 2017, to September 10, 2017.

SETTING AND PARTICIPANTS

570 Florida NHs that sheltered in place during Hurricane Irma.

METHODS

We stratified NHs by their NH Compare overall quality star rating and then measured change in direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants.

RESULTS

We found that the NH Compare overall star rating was positively associated with a greater staffing level response during Hurricane Irma among registered nurses, licensed practical nurses, and certified nursing assistants. This change was largest for 5-star facilities and smallest for 1-star facilities.

CONCLUSIONS AND IMPLICATIONS

Higher-quality NHs may be more responsive and have the resources to be more responsive, to increased needs during a natural disaster. Our findings may serve as a platform for ongoing discussion on the role of the federal, state, and local governments in ensuring minimum staffing standards during natural disasters.

Delivering, funding, and rating safe staffing levels and skills mix in aged care

BACKGROUND

Staffing levels and skill mix are critical issues within residential aged care. The positive impact of a sufficient number and skills mix of staff is upheld by abundant evidence within and beyond the sector. While being able to determine suitable staffing levels and skills mix to provide care to nursing home residents is vital, having an appropriate approach to funding the delivery of care is also critical. Beyond determining staffing levels and skills mix and funding care delivery, transparently rating the adequacy of staffing is also important to enable informed decision-making amongst consumers, policy makers, staff, and other stakeholders. There are existing tools for determining nursing home staffing levels and skills mix, funding care, and rating and reporting staffing, however there appears to be ongoing confusion regarding how these different tools might work together to achieve different things in order to ensure safe, quality care.

OBJECTIVES

In order to explain the importance of ensuring at least a minimum number (staffing level) of the right kind of staff (skills mix) to provide care to nursing home residents, in this paper we briefly explain key differences and interrelationships between three tools; one for determining staffing and skills mix, one for determining funding, and one for rating and reporting the level of staffing within a facility as a measure of quality.

RESULTS

Our explanation of the three existing tools has resulted in the development of a conceptual model for how minimum staffing levels and skills mix supports the delivery of safe, quality care and how this can be understood in relation to determining, funding, and rating staffing levels and skills mix.

CONCLUSIONS

Our conceptual model of how determining, funding, and rating staffing levels and skills mix relate to one another and fulfil different but related purposes can be used to demonstrate how minimum staffing levels and skills mix can be understood as foundational to ensuring respectful, safe, quality care.

Racial/Ethnic Disparities in Nursing Home End-of-Life Care: A Systematic Review

OBJECTIVE

Health disparities are pervasive in nursing homes (NHs), but disparities in NH end-of-life (EOL) care (ie, hospital transfers, place of death, hospice use, palliative care, advance care planning) have not been comprehensively synthesized. We aim to identify differences in NH EOL care for racial/ethnic minority residents.

DESIGN

A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered in PROSPERO (CRD42020181792).

SETTING AND PARTICIPANTS

Older NH residents who were terminally ill or approaching the EOL, including racial/ethnic minority NH residents.

METHODS

Three electronic databases were searched from 2010 to May 2020. Quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Eighteen articles were included, most (n = 16) were good quality and most (n = 15) used data through 2010. Studies varied in definitions and grouping of racial/ethnic minority residents. Four outcomes were identified: advance care planning (n = 10), hospice (n = 8), EOL hospitalizations (n = 6), and pain management (n = 1). Differences in EOL care were most apparent among NHs with higher proportions of Black residents. Racial/ethnic minority residents were less likely to complete advance directives. Although hospice use was mixed, Black residents were consistently less likely to use hospice before death. Hispanic and Black residents were more likely to experience an EOL hospitalization compared with non-Hispanic White residents. Racial/ethnic minority residents experienced worse pain and symptom management at the EOL; however, no articles studied specifics of palliative care (eg, spiritual care).

CONCLUSIONS AND IMPLICATIONS

This review identified NH health disparities in advance care planning, EOL hospitalizations, and pain management for racial/ethnic minority residents. Research is needed that uses recent data, reflective of current NH demographic trends. To help reduce EOL disparities, language services and cultural competency training for staff should be available in NHs with higher proportions of racial/ethnic minorities.

Determinants of Successful Nursing Home Accreditation

OBJECTIVES

This study examined the factors associated with better accreditation outcomes among nursing homes.

METHOD

A total of 538 nursing homes in Taiwan were included in this study. Measures included accreditation scores, external factors (household income, Herfindahl-Hirschman Index, old-age dependency ratio, population density, and number of older adult households), organizational factors (hospital-based status, chain-affiliated status, occupancy rate, the number of registered nurses or nurse aides per bed, and bed size), and internal factors (accountability, deficiencies, person-centered care, nursing skills, quality control, and integrated care).

RESULTS

Bed size, hospital-based status, accountability, deficiencies, person-centered care, nursing skills, quality control, and integrated care were found to predict accreditation.

CONCLUSION

Among all variables in this study, the quality indicators contributed to the most variation, followed by organizational factors. External environmental factors played a minor role in predicting accreditation. A focus on quality of care would benefit not only the residents of a nursing home but also facilitate its accreditation.

Socioeconomic inequalities in the place of death in urban small areas of three Mediterranean cities

BACKGROUND

Dying at home is the most frequent preference of patients with advanced chronic conditions, their caregivers, and the general population. However, most deaths continue to occur in hospitals. The objective of this study was to analyse the socioeconomic inequalities in the place of death in urban areas of Mediterranean cities during the period 2010-2015, and to assess if such inequalities are related to palliative or non-palliative conditions.

METHODS

This is a cross-sectional study of the population aged 15 years or over. The response variable was the place of death (home, hospital, residential care). The explanatory variables were: sex, age, marital status, country of birth, basic cause of death coded according to the International Classification of Diseases, 10th revision, and the deprivation level for each census tract based on a deprivation index calculated using 5 socioeconomic indicators. Multinomial logistic regression models were adjusted in order to analyse the association between the place of death and the explanatory variables.

RESULTS

We analysed a total of 60,748 deaths, 58.5% occurred in hospitals, 32.4% at home, and 9.1% in residential care. Death in hospital was 80% more frequent than at home while death in a nursing home was more than 70% lower than at home. All the variables considered were significantly associated with the place of death, except country of birth, which was not significantly associated with death in residential care. In hospital, the deprivation level of the census tract presented a significant association (p < 0.05) so that the probability of death in hospital vs. home increased as the deprivation level increased. The deprivation level was also significantly associated with death in residential care, but there was no clear trend, showing a more complex association pattern. No significant interaction for deprivation level with cause of death (palliative, not palliative) was detected.

CONCLUSIONS

The probability of dying in hospital, as compared to dying at home, increases as the socioeconomic deprivation of the urban area of residence rises, both for palliative and non-palliative causes. Further qualitative research is required to explore the needs and preferences of low-income families who have a terminally-ill family member and, in particular, their attitudes towards home-based and hospital-based death.

Relationship of Hospital Star Ratings to Race, Education, and Community Income

INTRODUCTION

The Centers for Medicare & Medicaid Services (CMS) publishes hospital quality ratings to provide more transparent and useable quality information to patients and stakeholders. However, there is a gap in the literature regarding the geographic distribution of the hospitals with higher star ratings. In this paper, we focus on the associations between star ratings and community characteristics, including racial/ethnic mix, household income, educational attainment, and regional difference.

METHODS

A retrospective study and cross-sectional logistic and multinomial logistic regression analyses.

RESULTS

According to the multivariate regression results, hospitals in areas with lower income, lower educational attainment, and higher minority population shares have lower quality ratings (lower income: odds ratio [OR] 0.67; 95% CI, 0.49-0.91; lower education: OR 0.66; 95% CI, 0.51-0.85; higher minority: OR 0.52; 95% CI, 0.40-0.69). Compared with hospitals in the Midwest, hospitals in Northeast, South, and West regions have lower quality ratings (Northeast: OR 0.37; 95% CI, 0.25-0.56; South: OR 0.68; 95% CI, 0.51-0.91; West: OR 0.69; 95% CI, 0.49-0.97).

DISCUSSION AND CONCLUSION

Overall, our results show that hospitals with higher star ratings are less likely to be located in communities with higher minority populations, lower income, and lower levels of educational attainment. Findings contribute to the discussion of integrating social factors in hospital quality star rating calculation methodologies.

Quality of Nursing Homes and Admission of Residents With Alzheimer's Disease and Related Dementias: The Potential Influence of Market Factors and State Policies

OBJECTIVES

This study aimed to examine the associations between nursing home (NH) quality and prevalence of newly admitted NH residents with Alzheimer's disease and related dementias (ADRD), and to assess the extent to which market-level wages for certified nursing assistants (CNAs) and state Medicaid behavioral and mental health add-on policy may influence such associations.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The analytical sample included 2777 NHs with either high or low quality, located in urban areas of 41 states from 2011 to 2014.

METHODS

The outcome variable was the prevalence of ADRD among newly admitted NH residents. NH quality was defined as dichotomous, based on the Nursing Home Compare (NHC) star rating system. We considered an NH with 5-star rating as having high quality and with 1-star rating as having low quality. Information on county-level CNA wages and state Medicaid behavioral and mental health add-on policies was included. Linear regression models with NH random effects and robust standard errors were estimated. A set of sensitivity analyses were performed.

RESULTS

After accounting for NH-level aggregated resident characteristics and market/state-level factors, the prevalence of ADRD among newly admitted residents was 3% lower in high-quality NHs compared with low-quality NHs (P < .01). A 1-dollar increase in CNA hourly wage was associated with a 0.9-percentage point decrease in the prevalence of ADRD among newly admitted residents (P < .01). State Medicaid behavioral and mental health add-on policy was associated with a 2.5-percentage point increase in the prevalence of ADRD in high-quality NHs (P < .05), but not in low-quality NHs.

CONCLUSIONS AND IMPLICATIONS

Our findings suggest that high-quality NHs are less likely to admit residents with ADRD. The effect size of this relationship is modest and may be influenced by state Medicaid behavioral and mental health add-on policies. Future studies are needed to better understand reasons leading to these associations so that effective interventions can be developed to incentivize high-quality NHs to more readily serve residents with ADRD.

Gunshot wounds to the head: racial disparities in inpatient management and outcomes

OBJECTIVE

Several studies have indicated that racial disparities may exist in the management and outcomes of acute trauma care. One segment of trauma care that has not been as extensively investigated, however, is that of cranial trauma care. The goal of this study was to determine whether significant differences exist among racial and ethnic groups in various measures of inpatient management and outcomes after gunshot wounds to the head (GWH).

METHODS

In this study, the authors used the Nationwide (National) Inpatient Sample (NIS) to investigate all-cause mortality, receipt of surgery, days from admission to initial intervention, discharge disposition, length of hospital stay, and total hospital charges of those with GWH from 2012 to 2016. A 1:1 propensity score–matched analysis was conducted to evaluate the effect of race on these endpoints, while controlling for baseline demographics and comorbidities.

RESULTS

A total of 333 patients met the inclusion and exclusion criteria: 148 (44.44%) white/Caucasian, 123 (36.94%) black/African American, 54 (16.22%) Hispanic/Latinx, and 8 (2.40%) Asian. African American patients were sent to immediate care and rehabilitation significantly less often than Caucasian patients (RR 0.17 [95% CI 0.04–0.71]). There were no significant differences in mortality, length of stay, rates of surgical intervention, or total hospital charges among any of the racial groups.

CONCLUSIONS

The authors’ findings suggest that racial disparities in inpatient cranial trauma care and outcomes may not be as prevalent as previously thought. In fact, the disparities seen were only in disposition. More research is needed to further elucidate and address disparities within this population, particularly those that may exist prior to, and after, hospitalization.

Nursing Home Star Ratings and New Onset of Depression in Long-Stay Nursing Home Residents

OBJECTIVES

To examine the association between nursing home (NH) quality and new onset of depression and severity of depressive symptoms in a national cohort of long-stay NH residents in the United States.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

129,837 long-stay residents without indicators of depression admitted to 13,921 NHs.

METHODS

NH quality was measured by Nursing Home Compare star ratings (overall, health inspection, staffing, quality measures) closest to admission. Study outcomes at 90 days from the Minimum Data Set 3.0 included depression diagnosis and severity of depressive symptoms (minimal; mild; moderate; moderately severe/severe). Symptoms were measured by resident self-report Patient Health Questionnaire (PHQ-9) or a staff-report observational version (PHQ-9-OV). Logistic and multinomial logistic models with generalized estimating equations were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

At 90 days postadmission, 14.1% of residents had a new diagnosis of depression, and odds did not differ across star ratings. Nearly 90% of these residents had minimal depressive symptoms, with only 8.5% reporting mild symptoms and 2.6% with moderate to severe symptoms. Using minimal depressive symptoms as the reference, residents in NHs with 5-star overall ratings were 12% less likely than those in 3-star NHs to experience mild (95% CI: 0.81-0.96) and 31% less likely to experience moderate symptoms (95% CI: 0.58-0.82). In NHs with 1-star staffing compared to 3-star, residents had 37% higher odds of moderate symptoms (95% CI: 1.14-1.64) and 57% higher odds of moderately severe to severe depressive symptoms (95% CI: 1.17-2.12). The odds of any above-minimal depressive symptoms decreased as quality measure ratings increased.

CONCLUSIONS/IMPLICATIONS

Lower NH quality ratings were associated with more severe depressive symptoms. Further investigation is warranted to identify potential mechanisms for a targeted intervention to improve quality and provide more equitable care.

A Healthcare Pathway to Nirvana? The SNF Transition to Home

While the majority of attention and the literature has focused on transitional models out of the acute care setting, transitions from the post-acute setting—especially from the skilled nursing facility (SNF)—are not well understood. What are the ‘best practices’, or thoughtful considerations, for a successful transition back to home and the community? Facilitation of a smooth and seamless transition relies on the abilities of the SNF and primary care teams, as well as community agencies, to coordinate care in a patient-centered manner together. This article will focus on this specific transition within the healthcare continuum.