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Smith JM, Burgdorf JG, Riser TJ, Ryvicker M. Skilled home healthcare utilization and outcomes for older adults with dementia: A scoping review. J Am Geriatr Soc 2024. [PMID: 39355968 DOI: 10.1111/jgs.19203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/21/2024] [Accepted: 09/10/2024] [Indexed: 10/03/2024]
Abstract
OBJECTIVES This study aims to summarize the existing research literature examining Medicare-skilled home health (HH) utilization and clinical outcomes for persons with dementia (PwD). We sought to answer the following questions: (1) How is dementia defined and classified in the HH literature? (2) What associations have been observed between dementia status and patterns of HH utilization? (3) What associations have been observed between dementia status and HH outcomes? METHODS Using Arksey and O'Malley's framework for scoping reviews, we searched PubMed, Google Scholar, and select relevant journals for quantitative studies conducted in the United States between 2000 and 2023 examining Medicare HH use and outcomes for PwD. We describe and compare approaches to classify dementia, identify findings related to HH utilization and outcomes supported by the preponderance of evidence, and comment on existing gaps and areas of ambiguity in the literature. RESULTS Thirty-two articles met the inclusion criteria. Most used claims-based data to classify dementia, leveraged national data, and were limited to traditional Medicare beneficiaries. Studies found meaningful differences in HH utilization by dementia status; most notably, PwD were more likely to access HH without a preceding hospitalization, had longer lengths of stay, and incurred higher HH costs. Literature relating to clinical outcomes was more difficult to interpret, due to significant variation in study objectives, samples, and outcome measures which prompted more nuanced and even contradictory conclusions. There is a dearth of research identifying how specific HH care pathways (e.g., service types, visit frequency) impact outcomes for this patient population. CONCLUSIONS This review supports the understanding that PwD are a unique subpopulation of HH patients who require special attention in policy development and evaluation. Critical research is needed to examine clinical outcomes in PwD further to inform practice and improve care quality.
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Affiliation(s)
- Jamie M Smith
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Julia G Burgdorf
- Center for Home Care Policy & Research at VNS Health, New York, New York, USA
| | | | - Miriam Ryvicker
- Center for Home Care Policy & Research at VNS Health, New York, New York, USA
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Ma C, Rajewski M, Smith JM. Medicare Advantage and Home Health Care: A Systematic Review. Med Care 2024; 62:333-345. [PMID: 38546388 PMCID: PMC10997464 DOI: 10.1097/mlr.0000000000001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
OBJECTIVES Home health care serves millions of Americans who are "Aging in Place," including the rapidly growing population of Medicare Advantage (MA) enrollees. This study systematically reviewed extant evidence illustrating home health care (HHC) services to MA enrollees. METHODS A comprehensive literature search was conducted in 6 electronic databases to identify eligible studies, which resulted in 386 articles. Following 2 rounds of screening, 30 eligible articles were identified. Each study was also assessed independently for study quality using a validated quality assessment checklist. RESULTS Of the 30 studies, nearly half (n=13) were recently published between January 1, 2017 - January 6, 2022. Among various issues related to HHC to MA enrollees examined, which were often compared with Traditional Medicare (TM) enrollees, the 2 most studied issues were HHC use rate (including access) and care dosage/intensity. Inconsistencies were common in findings across reviewed studies, with slight variations in the level of inconsistency by studied outcomes. Several critical issues, such as heterogeneity of MA plans, influence of MA-specific features, and program response to policy and quality improvement initiatives, were only examined by 1 or 2 studies. The depth and scope of scientific investigation were also limited by the scale and details available in MA data in addition to other methodological limits. CONCLUSIONS Wild variations and conflicting findings on HHC to MA beneficiaries exist across studies. More research with rigorous designs and robust MA encounter data is warranted to determine home health care for MA enrollees and the relevant outcomes.
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Affiliation(s)
- Chenjuan Ma
- Rory Meyers College of Nursing, New York University, New York, NY
| | - Martha Rajewski
- Rory Meyers College of Nursing, New York University, New York, NY
| | - Jamie M Smith
- School of Nursing, Johns Hopkins University, Baltimore, MD
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Wildes TM. Exploring Indicators of Vulnerability in Older Adults With Newly Diagnosed Multiple Myeloma. JCO Clin Cancer Inform 2024; 8:e2400013. [PMID: 38507666 DOI: 10.1200/cci.24.00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/06/2024] [Indexed: 03/22/2024] Open
Abstract
New publication provides insights into the impact of disability on outcomes in older adults with multiple myeloma.
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Affiliation(s)
- Tanya M Wildes
- University of Nebraska Medical Center/Nebraska Medicine, Omaha, NE
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Jensen CE, Kuo TM, LeBlanc MR, Baggett CD, Duchesneau ED, Zhou X, Reeder-Hayes KE, Lund JL. Functional Status Associations With Treatment Receipt and Outcomes Among Older Adults Newly Diagnosed With Multiple Myeloma. JCO Clin Cancer Inform 2024; 8:e2300214. [PMID: 38320226 PMCID: PMC10861012 DOI: 10.1200/cci.23.00214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/05/2023] [Accepted: 12/21/2023] [Indexed: 02/08/2024] Open
Abstract
PURPOSE Multiple myeloma (MM) is a prevalent hematologic malignancy in older adults, who often experience physical disability, increased health care usage, and reduced treatment tolerance. Home health (HH) services are frequently used by this group, but the relationship between disability, HH use, and MM treatment receipt is unclear. This study examines the connections between disability, treatment receipt, and survival outcomes in older adults with newly diagnosed MM using a nationwide data set. METHODS The SEER-Medicare data set was used to identify adults aged 66 years and older diagnosed with MM from 2010 to 2017, who used HH services the year before diagnosis. Disability was assessed with the Outcome and Assessment Information Set, using a composite score derived from items related to ability to complete activities of daily living. Mortality, therapy receipt, and health care utilization patterns were evaluated. RESULTS Of 37,280 older adults with MM, 6,850 (18.2%) used HH services before diagnosis. Moderate disability at HH assessment resulted in similar MM-directed therapy receipt as mild disability, with comparable health care usage after diagnosis to severe disability. HH users had a higher comorbidity burden and higher mortality (adjusted risk ratio for 3-year mortality: 1.59 [95% CI, 1.55 to 1.64]). Severe functional disability before diagnosis was strongly related to postdiagnosis mortality. CONCLUSION Among older adults with MM receiving HH services, disability is a predictor of early mortality. Moderately disabled individuals undergo similar therapy intensity as the mildly disabled but experience increased acute care utilization. Previous HH use could identify patients with MM requiring intensive support during therapy initiation.
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Affiliation(s)
| | - Tzy-Mey Kuo
- Cancer Information & Population Health Resource, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | | | - Christopher D. Baggett
- Cancer Information & Population Health Resource, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Emilie D. Duchesneau
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Xi Zhou
- Cancer Information & Population Health Resource, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Katherine E. Reeder-Hayes
- Cancer Information & Population Health Resource, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
- Division of Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jennifer L. Lund
- Cancer Information & Population Health Resource, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
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Oh A, Hunt LJ, Ritchie CS, Ornstein KA, Kelley AS, Rajagopalan S, Ankuda CK. Role of Home Health for Community-Dwelling Older Adults Near the End of Life: A Resource Beyond Hospice? J Palliat Med 2023; 26:385-392. [PMID: 36137095 PMCID: PMC9986009 DOI: 10.1089/jpm.2022.0272] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Medicare home health could be leveraged to care for those near the end of life (EOL), especially for those who cannot access nor desire the Medicare hospice benefit. It is unknown what role home health currently has either preceding or as an alternative to hospice use. Objective: The aim of this study is to compare populations served and visit patterns of Medicare beneficiaries receiving home health/hospice/both near the EOL. Design: Nationally representative cohort study of National Health and Aging Trends Study (NHATS) respondents. Setting/Subjects: A total of 1,057 U.S. decedents in NHATS from 2012 to 2017 with linked Medicare claims were included in this study. Measurements: Measurements included the proportion of decedents who received home health/hospice/both/neither (yes/no) in the last six months of life (EOL) and mean number of visits by discipline (nurse/therapist [physical/occupational speech-language pathologist]/social worker/home health aide) per 30 eligible days at home for home health/hospice/both at the EOL. The primary independent variable was the clinician discipline providing services (nurse/therapist/social worker/aide). Results: In our sample, 19.9% received home health only, 25.8% hospice only, 18.8% both, and 35.6% neither at the EOL. These populations varied in their demographic, region, and clinical characteristics. Decedents who received home health only compared with hospice only were younger (44.1% over age 85 vs. 58.4%), members of a racially/ethnically diverse group (19.7% vs. 10.9%), and with less disability (37.2% required no assistance with activities of daily living vs. 22.7%), all p values <0.05. In adjusted models, those receiving home health versus hospice received similar numbers of visits per 30 days (average 5.4/30 vs. 6.6/30), while those receiving both received more visits (10.5/30). Home health provided more therapy visits, while hospice provided more social work and aide visits. Conclusions: More than one in three Medicare decedents nationwide received home health at the EOL. Home health has the potential to serve a population not reached by hospice and improve the quality of end-of-life care.
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Affiliation(s)
- Anna Oh
- San Francisco VA Health Care System, San Francisco, California, USA
- Department of Social and Behavioral Sciences, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Lauren J Hunt
- Department of Physiological Nursing, University of California San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
| | - Christine S Ritchie
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Subashini Rajagopalan
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
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Sterling MR, Lau J, Rajan M, Safford M, Akinyelure OP, Kern LM. Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care. J Am Geriatr Soc 2023; 71:810-820. [PMID: 36468538 PMCID: PMC10023304 DOI: 10.1111/jgs.18135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/19/2022] [Accepted: 10/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Older adults see multiple outpatient providers and increasingly use home health care (HHC) services. Previous studies attempting to draw inferences about the association between HHC use and patient outcomes have been mixed. Whether HHC is associated with care coordination and how both influence outcomes are unknown. In addition, prior studies have not taken the patient perspective into account. We examined the association between receiving HHC and self-reported gaps in care coordination and separately, preventable adverse outcomes. METHODS The analysis for this cross-sectional study was conducted between October 2021 and June 2022, using data on 4296 Medicare beneficiaries from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who completed a survey on care coordination from 2017 to 2018. The associations between the receipt of HHC and two outcomes (a gap in care coordination, and separately, a preventable adverse event) were examined with Poisson models with robust standard errors. Potential confounders were accounted for through propensity score-based inverse probability weighting. RESULTS Among 4296 participants, 430 (10%) received HHC and they were older and had more comorbidities and ambulatory visits than those without HHC. HHC was not associated with differences in self-reported gaps in care coordination (33.3% HHC vs. 32.5% no-HHC, p = 0.70). HHC recipients reported more preventable drug-drug interactions (9.1% vs. 4.0%, p < 0.001) but not more preventable ED visits or hospital admissions. In IPW-adjusted models, HHC was not associated with gaps in care coordination (p = 0.60) but was associated with double the risk of a preventable adverse outcome (aRR 2.06; CI: 1.37, 3.10, p < 0.001). CONCLUSIONS HHC recipients were significantly more likely (than those without HHC) to report a potentially preventable adverse event (particularly a drug-drug interaction), suggesting an opportunity to improve patient safety by leveraging the observations of older adults receiving HHC.
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Affiliation(s)
| | - Jennifer Lau
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
| | - Mangala Rajan
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
| | - Monika Safford
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
| | | | - Lisa M. Kern
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
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Di M, Keeney T, Belanger E, Panagiotou OA, Olszewski AJ. Global Risk Indicator and Therapy for Older Patients With Diffuse Large B-Cell Lymphoma: A Population-Based Study. JCO Oncol Pract 2022; 18:e383-e402. [PMID: 34846916 PMCID: PMC8932488 DOI: 10.1200/op.21.00513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/04/2021] [Accepted: 10/27/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To examine the impact of global risk, a measure comprising age, comorbidities, function, and cognitive statuses, on treatment selection and outcomes among older home care recipients with diffuse large B-cell lymphoma. METHODS From SEER-Medicare, we selected home care recipients diagnosed with diffuse large B-cell lymphoma in 2011-2015, who had pretreatment Outcome and Assessment Information Set (OASIS) evaluations. We created a global risk indicator categorizing patients as low-, moderate-, or high-risk on the basis of OASIS assessments. We examined the association of global risk with receipt of therapy and among chemotherapy recipients, with mortality, emergency department visits, hospitalization, and intensive care unit admission within 30 days from first treatment in logistic models, reporting adjusted odds ratios (OR) with 95% CI. We compared overall survival across risk groups estimating adjusted hazard ratios. RESULTS Of the 1,232 patients (median age, 80 years), 65% received chemotherapy. High-risk patients (v moderate-risk) were less likely to receive any chemotherapy (OR, 0.50; 95% CI, 0.39 to 0.64) and curative regimens (OR, 0.59; 95% CI, 0.40 to 0.86) if treated, although even in the moderate-risk group, only 61% received curative regimens. High-risk patients were more likely to experience acute mortality (OR, 2.24; 95% CI, 1.43 to 3.52), emergency department visits (OR, 1.35; 95% CI, 1.00 to 1.83), hospitalization (OR, 1.60; 95% CI, 1.19 to 2.17), or intensive care unit admission (OR, 1.52; 95% CI, 1.04 to 2.22) and had inferior overall survival (hazard ratio, 1.41; 95% CI, 1.11 to 1.78). CONCLUSION Global risk on the basis of OASIS is easily available, suggesting a potential way to improve patient selection for curative treatment and institution of preventive measures.
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Affiliation(s)
- Mengyang Di
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI
- Division of Hematology/Oncology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT
| | - Tamra Keeney
- Mongan Institute, Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI
| | - Emmanuelle Belanger
- Mongan Institute, Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Orestis A. Panagiotou
- Mongan Institute, Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI
| | - Adam J. Olszewski
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI
- Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
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Casebeer AW, Ronning D, Schwartz R, Long C, Bhattacharya R, Uribe C, Brown CR, Cameron J, Painter P, Sharma A, Spitale S, Powers B, Stemple C, Shrank W. A Comparison of Home Health Utilization, Outcomes, and Cost Between Medicare Advantage and Traditional Medicare. Med Care 2022; 60:66-74. [PMID: 34739413 DOI: 10.1097/mlr.0000000000001661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Home health use is rising rapidly in the United States as the population ages, the prevalence of chronic disease increases, and older Americans express their desire to age at home. Enrollment in Medicare Advantage (MA) plans rather than Traditional Medicare (TM) has grown as well, from 13% of total Medicare enrollment in 2004 to 39% in 2020. Despite these shifts, little is known about outcomes and costs following home health in MA as compared with TM. OBJECTIVE The objective of this study was to measure the association of MA enrollment with outcomes and costs for patients using home health. DESIGN This was a retrospective cohort study. PARTICIPANTS Patients enrolled in plans offered by 1 large, national MA organization and patients enrolled in TM, with at least 1 home health visit between January 1, 2017, and June 30, 2018. EXPOSURE MA enrollment. MAIN MEASURES We compared the intensity of home health services and types of care delivered. The main outcome measures were hospitalization, the proportion of days in the home, and total allowed costs during the 180-day period following the first qualifying home health visit during the study period. KEY RESULTS Among patients who used home health, our models demonstrated enrollment in MA was associated with 14%, and 6% decreased odds of 60- and 180-day hospitalization, respectively, a 12.8% and 14.7% decrease in medical costs exclusive and inclusive of home health costs, respectively, and a 0.27% increase in the proportion of days at home during the 180-day follow-up, equivalent to an additional half-day at home. There were few differences in home health care delivered for MA and TM [mean number of visits in the first episode of care (17.1 vs. 17.3) and mean visits per week (3.2 vs. 3.3)]. The mean number of visits by visit type and percent of patients with each type was similar between MA and TM as well. CONCLUSIONS Compared with enrollment in TM, enrollment in MA was associated with improved patient-centered outcomes and lower cost and utilization, despite few differences in the way home health was delivered. These findings might be explained by structural components of MA that encourage better care management, but further investigation is needed to clarify the mechanisms by which MA enrollment may lead to higher value home health care.
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