A prediction rule for the use of postdischarge medical services

Predicting the need for supportive services after discharged from hospital: a systematic review

BACKGROUND

Some patients admitted to acute care hospital require supportive services after discharge. The objective of our review was to identify models and variables that predict the need for supportive services after discharge from acute care hospital.

METHODS

We performed a systematic review searching the MEDLINE, CINAHL, EMBASE, and COCHRANE databases from inception to May 1st 2017. We selected studies that derived and validated a prediction model for the need for supportive services after hospital discharge for patients admitted non-electively to a medical ward. We extracted cohort characteristics, model characteristics and variables screened and included in final predictive models. Risk of bias was assessed using the Quality in Prognostic Studies tool.

RESULTS

Our search identified 3362 unique references. Full text review identified 6 models. Models had good discrimination in derivation (c-statistics > 0.75) and validation (c-statistics > 0.70) cohorts. There was high quality evidence that age, impaired physical function, disabilities in performing activities of daily living, absence of an informal care giver and frailty predict the need for supportive services after discharge. Stroke was the only unique diagnosis with at least moderate evidence of an independent effect on the outcome. No models were externally validated, and all were at moderate or higher risk of bias.

CONCLUSIONS

Deficits in physical function and activities of daily living, age, absence of an informal care giver and frailty have the strongest evidence as determinants of the need for support services after hospital discharge.

TRIAL REGISTRATION

This review was registered with PROSPERO #CRD42016037144.

Living Alone and Discharge to Skilled Nursing Facility Care after Hospitalization in Older Adults

BACKGROUND/OBJECTIVES

Community-based older adults are increasingly living alone. When they become ill, they might need greater support from the healthcare system than would those who live with others. There also has been a growing concern about the high use of postacute care such as skilled nursing facility (SNF) care and the level of variation in this use between hospitals and regions. Our objective was to examine whether living alone contributed to the risk of being discharged to a SNF.

DESIGN

Retrospective cohort study.

SETTING

Massachusetts General Hospital.

PARTICIPANTS

Community-dwelling individuals aged 50 and older admitted to the medical service and discharged alive between July 2014 and August 2015 (N = 7,029).

MEASUREMENTS

We extracted demographic, clinical, and functional data from the electronic medical record and used multivariable logistic regression to determine whether living alone at the time of hospitalization was associated with subsequent discharge to a SNF.

RESULTS

Of eligible individuals, 24.8% reported living alone before admission. Those living alone were more likely to be female, older, and more independent before admission than those living with others. Of all participants, 10.9% were discharged to a SNF. After adjustment, participants living alone had more than twice the odds of being discharged to a SNF (odds ratio = 2.23, 95% confidence interval = 1.85-2.69, P < .001).

DISCUSSION

People living alone are more likely to be discharged to SNFs, even when compared to other individuals with similar levels of clinical complexity and functional status. To the extent that this variation is due to a lack of home support, it could be possible to reduce SNF use through additional home services after hospital discharge.

Validating Performance of a Hospital Discharge Planning Decision Tool in Community Hospitals

PURPOSE OF STUDY

The Early Screen for Discharge Planning (ESDP) is a decision support tool developed in an urban academic medical center. High ESDP scores identify patients with nonroutine discharge plans who would benefit from early discharge planning intervention. We aimed to determine the predictive performance of the ESDP in a different practice setting.

PRIMARY PRACTICE SETTING

Rural regional community hospital.

METHODOLOGY AND SAMPLE

We designed a comparative, descriptive survey study and enrolled a convenience sample of 222 patients (identified at admission) who provided informed consent. Sample characteristics and ESDP scores were collected during enrollment. The Problems After Discharge Questionnaire, EuroQoL-5Dimensions quality-of-life measure, length of stay, and use of post-acute care services were recorded after discharge. We compared outcomes between patients with low and high ESDP scores.

RESULTS

More than half of the sample (51.8%) had a high ESDP score. Patients with high ESDP scores reported more problems after discharge (p = .02), reported lower quality of life (p < .001), had longer length of stays (p = .04), and used post-acute care services (p = .006) more than patients with low ESDP scores. The difference in the average percentage of unmet needs was not statistically significant (p = .12), but patients with high ESDP scores reported more unmet needs than patients with low ESDP scores.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The value of systematically proactive approaches to discharge planning is increasingly recognized, but establishing the performance capacity of support tools is critical for optimizing benefit. These study findings support use of the ESDP in regional community hospitals, making it a useful, open-source decision support tool for various health care delivery systems.

Association Between Hospital Admission Risk Profile Score and Skilled Nursing or Acute Rehabilitation Facility Discharges in Hospitalized Older Adults

OBJECTIVES

To evaluate whether the Hospital Admission Risk Profile (HARP) score is associated with skilled nursing or acute rehabilitation facility discharge after an acute hospitalization.

DESIGN

Retrospective cohort study.

SETTING

Inpatient unit of a rural academic medical center.

PARTICIPANTS

Hospitalized individuals aged 70 and older from October 1, 2013 to June 1, 2014.

MEASUREMENTS

Participant age at the time of admission, modified Folstein Mini-Mental State Examination score, and self-reported instrumental activities of daily living 2 weeks before admission were used to calculate HARP score. The primary predictor was HARP score, and the primary outcome was discharge disposition (home, facility, deceased). Multivariate analysis was used to evaluate the association between HARP score and discharge disposition, adjusting for age, sex, comorbidities, and length of stay.

RESULTS

Four hundred twenty-eight individuals admitted from home were screened and their HARP scores were categorized as low (n = 162, 37.8%), intermediate (n = 157, 36.7%), or high (n = 109, 25.5%). Participants with high HARP scores were significantly more likely to be discharged to a facility (55%) than those with low HARP scores (20%) (P < .001). After adjustment, participants with high HARP scores were more than four times as likely as those with low scores to be discharged to a facility (odds ratio = 4.58, 95% confidence interval = 2.42-8.66).

CONCLUSION

In a population of older hospitalized adults, HARP score (using readily available admission information) identifies individuals at greater risk of skilled nursing or acute rehabilitation facility discharge. Early identification for potential facility discharges may allow for targeted interventions to prevent functional decline, improve informed shared decision-making about post-acute care needs, and expedite discharge planning.

Predictors of activity limitation and dependence on walking aids after primary total hip arthroplasty

OBJECTIVES

To study function outcomes and their predictors after primary total hip arthroplasty (THA).

DESIGN

Prospective cohort study.

SETTING

Mayo Clinic.

PARTICIPANTS

All patients who underwent primary THA at the Mayo Clinic between 1993 and 2005 and were alive at the time of follow-up.

MEASUREMENTS

Whether sex, age, body mass index (BMI), comorbidity, anxiety, and depression predict moderate to severe activity limitation (limitation in ≥3 activities) and complete dependence on waling aids 2 and 5 years after primary THA was examined. Multivariable logistic regression adjusted for operative diagnosis, American Society of Anesthesiologists score, implant type, and distance from medical center.

RESULTS

At 2 years, 30.3% of participants reported moderate to severe activity limitation; at 5 years, 35% of participants reported moderate to severe activity limitation. Significant predictors of moderate to severe activity limitations at 2-year follow-up were female sex (odds ratio (OR)=1.2, 95% confidence interval (CI)=1.1-1.4), aged 71 to 80 (OR=2.0, 95% CI=1.6-2.5), aged 80 and older (OR=4.5, 95% CI=3.4-6.0), depression (OR=2.1, 95% CI=1.6-2.7), and BMI greater than 30.0. At 5-year follow-up, significant predictors were aged 71 to 80 (OR=1.7, 95% CI=1.3-2.2), older than 80 (OR=4.3, 95% CI=2.8-6.6), depression (OR=2.3, 95% CI=1.6-3.4), and BMI greater than 30.0.Significant predictors of complete dependence on walking aids at 2 years were female sex (OR=2.0, 95% CI=1.4-2.7), aged 71 to 80 (OR=2.4, 95% CI=1.4-4.2), older than 80 (OR=11.4, 95% CI=6.0-21.9), higher Deyo-Charlson score (OR=1.5, 95% CI=(1.1-1.2) for 5-point increase, depression (OR=2.0, 95% CI=1.2-3.4), and BMI greater than 35.0. Each of these factors also significantly predicted complete dependence on walking at 5-year follow-up, with similar odds ratios, except that BMI of 30.0 to 34.9 was not significantly associated.

CONCLUSION

Higher BMI, depression, older age, and female sex predict activity limitation and complete dependence on walking aids 2 and 5 years after primary THA.

A predictive score to identify hospitalized patients' risk of discharge to a post-acute care facility

BACKGROUND

Early identification of patients who need post-acute care (PAC) may improve discharge planning. The purposes of the study were to develop and validate a score predicting discharge to a post-acute care (PAC) facility and to determine its best assessment time.

METHODS

We conducted a prospective study including 349 (derivation cohort) and 161 (validation cohort) consecutive patients in a general internal medicine service of a teaching hospital. We developed logistic regression models predicting discharge to a PAC facility, based on patient variables measured on admission (day 1) and on day 3. The value of each model was assessed by its area under the receiver operating characteristics curve (AUC). A simple numerical score was derived from the best model, and was validated in a separate cohort.

RESULTS

Prediction of discharge to a PAC facility was as accurate on day 1 (AUC: 0.81) as on day 3 (AUC: 0.82). The day-3 model was more parsimonious, with 5 variables: patient's partner inability to provide home help (4 pts); inability to self-manage drug regimen (4 pts); number of active medical problems on admission (1 pt per problem); dependency in bathing (4 pts) and in transfers from bed to chair (4 pts) on day 3. A score > or = 8 points predicted discharge to a PAC facility with a sensitivity of 87% and a specificity of 63%, and was significantly associated with inappropriate hospital days due to discharge delays. Internal and external validations confirmed these results.

CONCLUSION

A simple score computed on the 3rd hospital day predicted discharge to a PAC facility with good accuracy. A score > 8 points should prompt early discharge planning.

Pre-hospital discharge planning: empowering elderly patients through choice

Reductions in the length of stay for acute hospitalization have occurred as a result of Medicare cost containment strategies during the past 20 years. Thus, innovative approaches to the treatment of patients in the acute care hospital setting are necessary, particularly in the practice of discharge planning. The medical literature typically identifies the first day of admission as the time to begin discharge planning in order to minimize the patient's length of stay in the acute care hospital. This strategy has its limitations as elderly patients are often confused by unfamiliar surroundings, surgical anesthesia, postoperative pain, and the rapid pace of hospital recovery typically expected today. Consequently, options for discharge may be limited to the most expedient plan that will ensure safety and continued recovery. This article presents an alternative plan that begins with outpatient education preceding admission and follows the patient throughout the continuum of care including postdischarge.

The uniform postacute assessment tool: systematically evaluating the quality of measurement evidence

The U.S. Congress has mandated that the Centers for Medicare & Medicaid Services develop a uniform assessment instrument that characterizes patients' needs for postacute services. What scientific criteria should be used to evaluate the evidence for such a tool? The validity of a measure can be accurately graded only if the constructs measured and their applications are clearly defined. We argue that improving postacute placement is the main purpose of the uniform postacute assessment (recently renamed the Continuity Assessment Record and Evaluation). We argue that placement itself needs to be better defined and measured in terms of transitions in the level and type of treatment and care. Domains that should be measured to provide appropriate rehabilitative placement recommendations include level of skilled medical and nursing care, therapies, routine living support, family support, ability to participate in self-care, and patient preference. Almost no research has been performed to quantify and predict the needed intensity of rehabilitative therapy, a major lacuna in evidence. Criteria and examples are provided for research that will provide minimal, probably adequate, or strong evidence for the validity of systems that recommend care transitions. A long-term program of research and systematic evidence synthesis is needed to support guidelines that improve postacute placement.

Posthospital care transitions: patterns, complications, and risk identification

OBJECTIVES

To (1) describe patterns of posthospital care transitions; (2) characterize these patterns as uncomplicated or complicated; (3) identify those at greatest risk for complicated transitions.

DATA SOURCES/STUDY SETTING

The Medicare Current Beneficiary Survey was used to identify beneficiaries aged 65 and older who were discharged from an acute care hospital in 1997-1998.

STUDY DESIGN

Patterns of posthospital transfers were described over a 30-day time period following initial hospital discharge. Uncomplicated posthospital care patterns were defined as a sequence of transfers from higher-to lower-intensity care environments without recidivism, while complicated posthospital care patterns were defined as the opposite sequence of events. Indices were developed to identify patients at risk for complicated transitions.

PRINCIPAL FINDINGS

Forty-six distinct types of care patterns were observed during the 30 days following hospital discharge. Among these patterns, 444 episodes (61.2 percent) were limited to a single transfer, 130 episodes (17.9 percent) included two transfers, 62 episodes (8.5 percent) involved three transfers, and 31 episodes (4.3 percent) involved four or more transfers. Fifty-nine episodes (8.1 percent) resulted in death. Between 13.4 percent and 25.0 percent of posthospital care patterns in the 1998 sample were classified as complicated. The area under the receiver operating curve was 0.771 for a predictive index that utilized administrative data and 0.833 for an index that used a combination of administrative and self-reported data.

CONCLUSIONS

Posthospital care transitions are common among Medicare beneficiaries and patterns of care vary greatly. A significant number of beneficiaries experienced complicated care transitions-a finding that has important implications for both patient safety and cost-containment efforts. Patients at risk for complicated care patterns can be identified using data available at the time of hospital discharge.

Discharge Planning Process

Discharge planning is an integral but ill-defined process in most acute care settings. The time available to a healthcare team to adequately prepare patients for discharge has virtually evaporated with decreasing lengths of hospital stay. A research utilization (RU) team at a tertiary care teaching institution reviewed the literature from 1990 to 2002 in search of a research-based practice regarding staff nurses' roles in the discharge process. Review of the literature revealed varied discharge planning processes using staff nurses, advanced practice nurses, or case managers specifically prepared to implement the discharge planning process. Insufficient evidence was found to support a change from the current staff nurse practice.

Intraindividual change in SF-36 in ambulatory clinic primary care patients predicted mortality and hospitalizations

OBJECTIVE

We sought to determine whether change in SF-36 scores over time is associated with the risk of adverse outcomes.

STUDY DESIGN AND SETTING

7,702 participants in the Ambulatory Care Quality Improvement Project who completed a baseline and 1-year SF-36. Using logistic regression methods we estimated the 1-year risk of hospitalization and death based on previous 1-year changes in the physical (PCS) and mental (MCS) component summary scores.

RESULTS

After adjusting for baseline PCS scores, age, VA hospital site, distance to VA, and comorbidity, a >10-point decrease in PCS score was associated with an increased risk of death (OR 2.3, 95% CI 1.6-3.4) and hospitalization (OR 1.8, 1.4-2.2). An increased risk was also seen with a >10-point decrease in the MCS (OR for death, 1.6, 1.1-2.3; OR for hospitalization 1.5, 1.2-1.8).

CONCLUSION

Change in SF-36 PCS and MCS scores is associated with mortality and hospitalizations, and provides important prognostic information over baseline scores alone.

Correlative analysis of lateral vertebral radiographic variables and medical outcomes study short-form health survey: a comparative study in asymptomatic volunteers versus patients with low back pain

This prospective comparative study was designed to investigate the possible link between SF-36 functional status and lateral roentgenographic variables of the standing lumbar spine in patients with low back pain (LBP) versus asymptomatic volunteers. To the authors' knowledge, no previous studies have correlated SF-36 scores and sagittal roentgenographic variables in patients with LBP versus asymptomatic individuals. A total of 100 male volunteers, used as controls, and an equal number of age-, height-, and weight-comparable patients of the same ethnicity with chronic LBP were compared on the basis of roentgenographic and SF-36 data. The roentgenographic variables that were measured included the following: lumbar lordosis, sacral inclination, L1-S1 vertebral inclination, L4-S1 distal lordosis, disc index, and L1-L5 vertebral index. These variables were correlated with the eight SF-36 scales both in patients and controls. As the patients with LBP get older, they show lower functional scores in Role-Emotional (p < 0.01) and Physical Functioning (p < 0.01). Body height was not found to be a predisposition favoring LBP, but tall patients with LBP showed less Bodily Pain than patients of short stature (p < 0.001). This study showed that patients with LBP had significantly lower scores than their asymptomatic counterparts in the following SF-36 scales: Role-Physical (p < 0.01), Bodily Pain (p < 0.01), Role-Emotional (p = 0.058), and Mental Health (p < 0.001). In the controls General Health, Physical Functioning, Social Functioning, and Role-Emotional, Bodily Pain, Mental Health, and Vitality correlated statistically significantly with individuals' age, height, weight, lumbar lordosis, sacral inclination, inclination of L1, L3, and L5 vertebra, L1-L5 vertebral index, and L1-L2, L2-L3, L3-L4, L4-L5, and L5-S1 disc index. For the patients with LBP this study showed that General health, Physical Functioning, Role-Emotional, Social Functioning, and Bodily Pain were significantly correlated with age, height, L1-L2 inclination, distal lordosis, L2-L5 index, and L4-L5 and L5-S1 disc index. This comparative study showed that the functional status of hard-working patients with chronic LBP is associated with degenerative changes on the lateral radiographs of the lumbosacral spine. Spine surgeons should take into consideration the results of this study in reconstruction of painful degenerative lumbosacral spine.

Effect of case managers with a general medical patient population

The objectives of this study were to evaluate the effect of inpatient case management (CM) on a general medical service and to determine if a prediction rule, identifying patients likely to need discharge planning services, could define a subset of patients for whom CM would be most effective. We hypothesized that CM would have greatest impact on patients predicted to be at highest risk of needing discharge planning to arrange for post-discharge medical services. We carried out a prospective controlled study. Six general medicine teams from a 600-bed urban teaching hospital were randomly assigned to CM (n = 4) or standard care (SC) (n = 2). Number of patients = 302 (207 CM; 95 SC). Case managers participated in daily physician team rounds and coordinated discharge planning for CM patients; SC patients received discharge planning from staff nurses or discharge planners when requested by physicians. The outcomes measured were deviation from the hospital length of stay (LOS) expected for a patient's diagnosis, patient satisfaction and non-acute medical service utilization during the month after discharge. Overall, patients from CM and SC teams did not differ in their deviation from expected LOS, post-discharge medical service utilization and patient satisfaction. However, after stratifying patients by their predicted need for post-discharge medical services, only patients in the 'high risk' category had a significantly shorter LOS under CM (2.9 days shorter than SC patients; P = 0.02). We concluded that, in this study, the effect of case managers on a general medical service was limited to shortening LOS only among a stratum of high risk patients.

The association of the SF-36 health status survey with 1-year socioeconomic outcomes in a chronically disabled spinal disorder population

STUDY DESIGN

The Short Form Health Survey (SF-36) was administered to patients with chronic spinal disorders both before and after tertiary rehabilitation. The association of the SF-36 with various socioeconomic outcomes was then examined.

OBJECTIVES

To assess the correlation of scores on SF-36 with treatment program completion and clinically meaningful 1-year socioeconomic outcomes.

SUMMARY OF BACKGROUND DATA

There has been much interest in identifying variables that can predict which disabled workers with chronic spinal disorders will have good versus poor socioeconomic outcomes after tertiary rehabilitation. Results of previous research have indicated that psychosocial factors are better predictors of such outcomes than physical factors. A more recent trend in research is assessing health-related quality of life from the health care recipient's perspective.

METHODS

The SF-36 was administered to a cohort (n = 146) of patients chronically disabled by spinal disorders before entry into a tertiary functional restoration program. Of this cohort, preprogram SF-36 scores and 1-year socioeconomic data were available for 128 program completers and 18 program noncompleters. The pre- and postprogram SF-36 scores of program completers for each of the outcome variables were compared.

RESULTS

Better scores on the preprogram SF-36 Social Functioning and Bodily Pain scales were found to be associated with successful completion of the treatment program. Postprogram SF-36 scores were more frequently associated with outcomes than were preprogram scores. Most SF-36 scores, especially the physical domain scales, were associated with the variables of return to work, work retention, and use of health care resources. The overwhelming majority of significant associations were between higher (i.e., better) SF-36 scores and "good" treatment outcomes (e.g., return-to-work).

CONCLUSIONS

The large number of associations between SF-36 scores and outcome variables highlights the importance of assessing the health-related quality of life of patients, and supports the use of the SF-36 in accomplishing this task. Among the findings, perhaps the most significant was the value of assessing health-related quality of life, particularly the subjective physical components, after completion of a functional restoration program. Prediction of long-term socioeconomic outcomes is likely to be improved if assessment is conducted at the end of the treatment process. SF-36 is recommended for assessing general health status, and more spine-specific measures are recommended for assessing spinal pain and disability variables.