Does hospitalization impact survival after lower respiratory infection in nursing home residents?

Outcomes for Long-Stay Nursing Facility Residents Following On-Site Acute Care under a CMS Initiative

OBJECTIVES

The goal of this study was to describe outcomes of long-term nursing facility (NF) residents treated for one of 6 conditions on-site in the NF and to compare outcomes to those treated for the same conditions in the hospital.

DESIGN

Cross-sectional retrospective study.

SETTINGS AND PARTICIPANTS

The Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents-Payment Reform enabled participating NFs to bill Medicare for providing on-site care to eligible long-stay residents meeting specified severity criteria due to any of 6 medical conditions, as an alternative to hospitalization. For billing purposes, residents were required to meet clinical criteria severe enough to warrant hospitalization.

METHODS

We used the Minimum Data Set assessments to identify eligible long-stay NF residents. We used Medicare data to identify residents who were treated, either on-site or in the hospital, for the 6 conditions and measure outcomes including subsequent hospitalization and death. To compare residents treated in the 2 modes, we used logistic regression models and adjusted for demographics, functional and cognitive status, and comorbidities.

RESULTS

Among residents treated on-site for the 6 conditions, 13.6% were subsequently hospitalized and 7.8% died, within 30 days, compared to 26.5% and 17.0%, respectively, among those treated in the hospital. Based on multivariate analysis, those treated in the hospital were more likely to be readmitted (OR = 1.666, P < .001) or to die (OR = 2.251, P < .001).

CONCLUSIONS AND IMPLICATIONS

Although unable to fully account for differences in unobserved severity of illness between residents treated on-site vs in the hospital, our results do not indicate any harm, but rather a possible benefit, to being treated on-site.

[Nursing home-sensitive conditions and approaches to reduce hospitalization of nursing home residents]

BACKGROUND

Interventions to reduce potentially risky hospitalizations among nursing home residents are highly relevant for patient safety and quality improvement. A catalog of nursing home-sensitive conditions (NHSCs) grounds the policy recommendations and interventions.

METHODS

In two previous research phases, an expert panel developed a catalog of 58 NHSCs using an adapted Delphi-procedure (the RAND/UCLA Appropriateness Method). This procedure was developed by the North American non-profit Research and Development Organisation (RAND) and clinicians of the University of California in Los Angeles (UCLA). We present the third phase of the project focused on the development of interventions to reduce NHSCs starting with an expert workshop. The workshop results were then evaluated by six experts from related sectors, supplemented, and systematically used to produce recommendations for action. Possible implementation obstacles were considered and the time horizon of effectiveness was estimated.

RESULTS

The recommendations address communication, cooperation, documentation and care competence as well as facility-related, financial, and legal aspects. Indication bundles demonstrate the relevance for the German healthcare system. To increase effectiveness, the experts advise a meaningful combination of individual recommendations.

DISCUSSION

By optimizing multidisciplinary communication and cooperation, combined with an- also digital - expansion of the infrastructure and the creation of institution-specific and legal prerequisites as well as remuneration structures, an estimated 35% of all hospitalizations, approximately 220,000 hospitalizations for Germany, could be prevented. The implementation expenditure could be refinanced by avoided hospitalization savings amounting to 768 million euros.

Utility of hospitalization for elderly individuals affected by COVID-19

Background

During the COVID-19 pandemic, the number of individuals needing hospital admission has sometimes exceeded the availability of hospital beds. Since hospitalization can have detrimental effects on older individuals, preference has been given to younger patients. The aim of this study was to assess the utility of hospitalization for elderly affected by COVID-19. We hypothesized that their mortality decreases when there is greater access to hospitals.

Methods

This study examined 1902 COVID-19 patients consecutively admitted to three large hospitals in Milan, Italy. Overall mortality data for Milan from the same period was retrieved. Based on emergency department (ED) data, both peak and off-peak phases were identified. The percentage of elderly patients admitted to EDs during these two phases were compared by calculating the standardized mortality ratio (SMR) of the individuals younger than, versus older than, 80 years.

Results

The median age of the patients hospitalized during the peak phase was lower than the median age during the off-peak phase (64 vs. 75 years, respectively; p <0.001). However, while the SMR for the younger patients was lower during the off-peak phase (1.98, 95% CI: 1.72–2.29 versus 1.40, 95% CI: 1.25–1.58, respectively), the SMR was similar between both phases for the elderly patients (2.28, 95% CI: 2.07–2.52 versus 2.48, 95% CI: 2.32–2.65, respectively).

Conclusions

Greater access to hospitals during an off-peak phase did not affect the mortality rate of COVID-19-positive elderly patients in Milan. This finding, if confirmed in other settings, should influence future decisions regarding resource management of health care organizations.

Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia

Objectives

Pneumonia is a common cause of hospitalization for nursing home residents and has increased as a cause for hospitalization during the COVID-19 pandemic. Risks of hospitalization, including significant functional decline, are important considerations when deciding whether to treat a resident in the nursing home or transfer to a hospital. Little is known about postdischarge functional status, relative to baseline, of nursing home residents hospitalized for pneumonia. We sought to determine the risk of severe functional limitation or death for nursing home residents following hospitalization for treatment of pneumonia.

Design

Retrospective cohort study.

Setting and Participants

Participants included Medicare enrollees aged ≥65 years, hospitalized from a nursing home in the United States between 2013 and 2014 for pneumonia.

Methods

Activities of daily living (ADL), patient sociodemographics, and comorbidities were obtained from the Minimum Data Set (MDS), an assessment tool completed for all nursing home residents. MDS assessments from prior to and following hospitalization were compared to assess for functional decline. Following hospital discharge, all patients were evaluated for a composite outcome of severe disability (≥4 ADL limitations) following hospitalization or death prior to completion of a postdischarge MDS.

Results

In 2013 and 2014, a total of 241,804 nursing home residents were hospitalized for pneumonia, of whom 89.9% (192,736) experienced the composite outcome of severe disability or death following hospitalization for pneumonia. Although we found that prehospitalization functional and cognitive status were associated with developing the composite outcome, 53% of residents with no prehospitalization ADL limitation, and 82% with no cognitive limitation experienced the outcome.

Conclusions and Implications

Hospitalization for treatment of pneumonia is associated with significant risk of functional decline and death among nursing home residents, even those with minimal deficits prior to hospitalization. Nursing homes need to prepare for these outcomes in both advance care planning and in rehabilitation efforts.

Geriatric Palliative Care

In the geriatric age group, few studies demonstrate the efficacy of aggressive treatment. Often, a more palliative approach is wanted; such an approach can lead to better quality of life and even a longer life. The author discusses the limits of medical interventions in the elderly, the paucity of data, and the benefits of palliation in certain medical conditions, including dementia, Parkinson, depression, arthritis, congestive heart failure, and pneumonia. The role of frailty is addressed; specific goals of palliative care are delineated, such as reduction of polypharmacy, fall prevention, pain reduction, and the central role of a primary care provider.

Physician's perception leading to the transfer of a dying nursing home resident to an emergency department: A French qualitative study

AIM

The aim of the present study was to find out physicians' perceptions about the transfer of dying nursing home residents to emergency departments.

METHOD

This qualitative study used semi-structured interviews, and data were analyzed using qualitative methods. Participants were medical directors of nursing homes who were informed by e-mail and included when they agreed to take part in our study.

RESULTS

We interviewed 12 medical directors until data saturation. The following themes emerged: (i) related to the resident - difficulties in identifying the end of life, refractory symptoms and lack of knowledge of the resident's wishes; (ii) related to the family - denial of the end of life/fear of death, lack of confidence in the nursing home and conflict among family members; (iii) related to the nursing staff - fear of death, lack of communication, lack of training, lack of staff (especially of nurses during the nightshift) and use of temporary employees; and (iv) related to the physicians - lack of anticipation of the end of life situation, difficulty in accessing some drugs, inadequate working hours in the nursing home, conflicting medical opinions of the GP and medical director, and lack of training on palliative care issues.

CONCLUSIONS

These results suggest many ways of reducing the transfer of dying residents to emergency departments through palliative care training, and communication about advance care planning. Geriatr Gerontol Int 2019; 19: 249-253.

Bacterial Pneumonia in Older Adults

The incidence of pneumonia increases with age, and is particularly high in patients who reside in long-term care facilities (LTCFs). Mortality rates for pneumonia in older adults are high and have not decreased in the last decade. Atypical symptoms and exacerbation of underlying illnesses should trigger clinical suspicion of pneumonia. Risk factors for multidrug-resistant organisms are more common in older adults, particularly among LTCF residents, and should be considered when making empiric treatment decisions. Monitoring of clinical stability and underlying comorbid conditions, potential drug-drug interactions, and drug-related adverse events are important factors in managing elderly patients with pneumonia.

Predictors of mortality in nursing-home residents with pneumonia: a multicentre study

OBJECTIVES

To evaluate predictors of mortality in patients residing in nursing-homes (NHs) or long-term care facilities (LTCFs) with diagnosis of NH-acquired pneumonia (NHAP).

METHODS

We conducted an observational, prospective study (December 2013-December 2015) of patients residing in nine NHs/LTCFs of Central and Northern Italy with diagnosis of NHAP. Data on demographics, comorbidities, microbiology, and therapies were entered into an electronic database. To identify risk factors associated with 30-day mortality, we performed univariable and multivariable analyses, and predictors were internally validated using a bootstrap resampling procedure. We derived a prediction rule using the coefficients obtained from the multivariable logistic regression. The model obtained was assessed using the area under the receiver operating characteristic curve (AUROC).

RESULTS

Overall, 446 patients with NHAP were included in the final cohort. The median age was 80 (IQR 75-87) years. A definite aetiology was obtained in 120 (26.9%) patients; of these, 66 (55%) had a culture positive for a multidrug-resistant pathogen. The 30-day mortality was 28.7%. On multivariate analysis, malnutrition (OR 7.8; 95% CI 3-20.2, 2 points), bilateral pneumonia (OR 3.7; 95% CI 1.4-9.8, 1 point), acute mental status deterioration (OR 6.2; 95% CI 2.2-17.6, 2 points), hypotension (OR 7.7; 95% CI 2.3-24.9, 2 points), and PaO₂/FiO₂ ratio ≤250 (OR 7.4; 95% CI 2.2-24.2, 2 points) were independently associated with 30-day mortality. The derived prediction rule showed an AUROC of 0.83 (95% CI 0.78-0.87, p <0.001).

CONCLUSIONS

NH residents with pneumonia have specific risk factors associated with 30-day mortality. Malnutrition and acute mental change appear as major determinants of death in this population.

Preventing Burdensome Transitions of Nursing Home Residents with Advanced Dementia: It's More than Advance Directives

BACKGROUND

Although a palliative approach to care is recommended for people with advanced dementia, many nursing home (NH) residents with dementia experience burdensome interventions such as hospital transfers at the end of life.

OBJECTIVE

The goal of this study was to examine how decisions to transfer NH residents with advanced dementia are made, from the perspective of NH nurses and physicians.

METHODS

A qualitative, descriptive method was used. Purposive sampling was used to recruit 20 healthcare providers from 9 NHs. Data collection included semistructured, open-ended interviews.

RESULTS

Decision making regarding hospital transfer comprised two phases. Phase one, laying the groundwork, was influenced by the ability of the providers to effectively establish trust, foreshadow, and illuminate hazards of hospitalization. Phase two, responding to an acute event, began at the start of an acute event and ended when a decision was made to either treat the resident in the NH or transfer to the hospital. Responding to the acute event was influenced by the ability to care for residents in the NH, the providers' comfort with end-of-life conversations, and surrogates' preferences.

CONCLUSIONS

Advance care planning before an acute event is only the first step in a process of decision making. Attention to and support for decision making is needed at the time of each acute event to ensure that goals of care are maintained.

Is tube feeding futile in advanced dementia?

It is controversial whether tube feeding in people with dementia improves nutritional status or prolongs survival. Guidelines published by several professional societies cite observational studies that have shown no benefit and conclude that tube feeding in patients with advanced dementia should be avoided. However, all studies on tube feeding in dementia have major methodological flaws that invalidate their findings. The present evidence is not sufficient to justify general guidelines. Patients with advanced dementia represent a very heterogeneous group, and evidence demonstrates that some patients with dementia benefit from tube feeding. However, presently available guidelines make a single recommendation against tube feeding for all patients. Clinicians, patients, and surrogates should be aware that the guidelines and prior commentary on this topic tend both to overestimate the strength of evidence for futility and to exaggerate the burdens of tube feeding. Shared decision making requires accurate information tailored to the individual patient's particular situation, not blanket guidelines based on flawed data. Lay Summary: Many doctors believe that tube feeding does not help people with advanced dementia. Scientific studies suggest that people with dementia who have feeding tubes do not live longer or gain weight compared with those who are carefully hand fed. However, these studies are not very helpful because of flaws in design, which are discussed in this article. Guidelines from professional societies make a blanket recommendation against feeding tubes for anyone with dementia, but an individual approach that takes each person's situation into account seems more appropriate. Patients and surrogates should be aware that the guidelines on this topic tend both to underestimate the benefit and exaggerate the burdens of tube feeding.

Emergency department transfers and hospital admissions from residential aged care facilities: a controlled pre-post design study

BACKGROUND

Older people living in Residential Aged Care Facilities (RACF) are a vulnerable, frail and complex population. They are more likely than people who reside in the community to become acutely unwell, present to the Emergency Department (ED) and require admission to hospital. For many, hospitalisation carries with it risks. Importantly, evidence suggests that some admissions are avoidable. A new collaborative model of care, the Aged Care Emergency Service (ACE), was developed to provide clinical support to nurses in the RACFs, allowing residents to be managed in place and avoid transfer to the ED. This paper examines the effects of the ACE service on RACF residents' transfer to hospital using a controlled pre-post design.

METHODS

Four intervention RACFs were matched with eight control RACFs based on number of total beds, dementia specific beds, and ratio of high to low care beds in Newcastle, Australia, between March and November 2011. The intervention consisted of a clinical care manual to support care along with a nurse led telephone triage line, education, establishing goals of care prior to ED transfer, case management when in the ED, along with the development of collaborative relationships between stakeholders. Outcomes included ED presentations, length of stay, hospital admission and 28-day readmission pre- and post-intervention. Generalised estimating equations were used to estimate mean differences in outcomes between intervention and controls RACFs, pre- and post-intervention means, and their interaction, accounting for repeated measures and adjusting for matching factors.

RESULTS

Residents had a mean age of 86 years. ED presentations ranged between 16 and 211 visits/100 RACF beds/year across all RACFs. There was no overall reduction in ED presentations (OR = 1.17, p = 0.56) with the ACE intervention. However, when compared to the controls, the intervention group reduced their ED length of stay by 45 min (p = 0.0575), and was 40 % less likely to be admitted to hospital, . The latter was highly significant (p = 0.0012).

CONCLUSIONS

Transfers to ED and admission to hospital are common for residents of RACFs. This study has demonstrated that a complex multi-strategy intervention led by nursing staff can successfully reduce hospital admissions for older people living in Residential Aged Care Facilities. By defining goals of care prior to transfer to the ED, clinicians have the opportunity to better deliver care that patients require. Integrated care requires accountability from multiple stakeholders.

TRIAL REGISTRATION

The Australian New Zealand Clinical Trials Registration number is ACTRN12616000588493 It was registered on 6(th) May 2016.

Emergency department transfers and hospital admissions from residential aged care facilities: a controlled pre-post design study

BACKGROUND

Older people living in Residential Aged Care Facilities (RACF) are a vulnerable, frail and complex population. They are more likely than people who reside in the community to become acutely unwell, present to the Emergency Department (ED) and require admission to hospital. For many, hospitalisation carries with it risks. Importantly, evidence suggests that some admissions are avoidable. A new collaborative model of care, the Aged Care Emergency Service (ACE), was developed to provide clinical support to nurses in the RACFs, allowing residents to be managed in place and avoid transfer to the ED. This paper examines the effects of the ACE service on RACF residents' transfer to hospital using a controlled pre-post design.

METHODS

Four intervention RACFs were matched with eight control RACFs based on number of total beds, dementia specific beds, and ratio of high to low care beds in Newcastle, Australia, between March and November 2011. The intervention consisted of a clinical care manual to support care along with a nurse led telephone triage line, education, establishing goals of care prior to ED transfer, case management when in the ED, along with the development of collaborative relationships between stakeholders. Outcomes included ED presentations, length of stay, hospital admission and 28-day readmission pre- and post-intervention. Generalised estimating equations were used to estimate mean differences in outcomes between intervention and controls RACFs, pre- and post-intervention means, and their interaction, accounting for repeated measures and adjusting for matching factors.

RESULTS

Residents had a mean age of 86 years. ED presentations ranged between 16 and 211 visits/100 RACF beds/year across all RACFs. There was no overall reduction in ED presentations (OR = 1.17, p = 0.56) with the ACE intervention. However, when compared to the controls, the intervention group reduced their ED length of stay by 45 min (p = 0.0575), and was 40 % less likely to be admitted to hospital, . The latter was highly significant (p = 0.0012).

CONCLUSIONS

Transfers to ED and admission to hospital are common for residents of RACFs. This study has demonstrated that a complex multi-strategy intervention led by nursing staff can successfully reduce hospital admissions for older people living in Residential Aged Care Facilities. By defining goals of care prior to transfer to the ED, clinicians have the opportunity to better deliver care that patients require. Integrated care requires accountability from multiple stakeholders.

TRIAL REGISTRATION

The Australian New Zealand Clinical Trials Registration number is ACTRN12616000588493 It was registered on 6(th) May 2016.

Differences in caregiver daily impression by sex, education and career length

AIM

We previously proposed the concept of caregiver daily impression (CDI) as a practical tool for emergency triage. We herein assessed how CDI varies by sex, education and career length by determining CDI scores as quantitative outcome measures.

METHODS

We carried out a cross-sectional study using a self-reported questionnaire among caregivers in 20 long-term care facilities in Hyogo, Japan. A total of 10 CDI variables measured participants' previous experience of emergency transfers using a scale from 0-10. The resulting total was defined as the CDI score. We hypothetically considered that higher scores indicated greater caregiver focus. The CDI scores were compared by sex, education and career length using analysis of covariance.

RESULTS

A total of 601 personal caregivers were evaluated (mean age 36.7 years; 36% men). The mean career length was 6.9 years, with the following groupings: 1-4 years (38%), 5-9 years (37%) and >10 years (24%). After adjustment for sex and education, the CDI scores for the variable, "poor eye contact," significantly differed between caregivers with ≥10 and <5 years of experience (scores of 5.0 ± 3.1 and 4.0 ± 2.7, respectively). The CDI scores for variables related to eyes tended to increase with experience, whereas other CDI scores decreased. Male caregivers focused on residents' eyes significantly more than did female caregivers.

CONCLUSIONS

We found that the CDI variable, "poor eye contact," is influenced by career length. Caregivers with more experience attach more importance to their impression of residents' eyes than do those with less experience. Sex-related differences in CDI might also exist. Geriatr Gerontol Int 2016; 17: 410-415.

The Impact of Medicaid Payer Status on Hospitalizations in Nursing Homes

OBJECTIVES

To examine the association between payer status (Medicaid vs. private-pay) and the risk of hospitalizations among long-term stay nursing home (NH) residents who reside in the same facility.

DATA AND STUDY POPULATION

The 2007-2010 National Medicare Claims and the Minimum Data Set were linked. We identified newly admitted NH residents who became long-stayers and then followed them for 180 days.

ANALYSES

Three dichotomous outcomes-all-cause, discretionary, and nondiscretionary hospitalizations during the follow-up period-were defined. Linear probability model with facility fixed-effects and robust SEs were used to examine the within-facility difference in hospitalizations between Medicaid and private-pay residents. A set of sensitivity analyses were performed to examine the robustness of the findings.

RESULTS

The prevalence of all-cause hospitalization during a 180-day follow-up period was 23.3% among Medicaid residents compared with 21.6% among private-pay residents. After accounting for individual characteristics and facility effects, the probability of any all-cause hospitalization was 1.8-percentage point (P<0.01) higher for Medicaid residents than for private-pay residents within the same facility. We also found that Medicaid residents were more likely to be hospitalized for discretionary conditions (5% increase in the likelihood of discretionary hospitalizations), but not for nondiscretionary conditions. The findings from the sensitivity analyses were consistent with the main analyses.

CONCLUSIONS

We observed a higher hospitalization rate among Medicaid NH residents than private-pay residents. The difference is in part driven by the financial incentives NHs have to hospitalize Medicaid residents.

Caregiver daily impression could reflect illness latency and severity in frail elderly residents in long-term care facilities: A pilot study

AIMS

To propose a caregiver daily impression (CDI) rating instrument for personal caregivers of residents living in long-term care facilities (LTCF) to comprehensively evaluate residents' daily health condition, and to investigate whether the CDI reflects illness latency and severity in residents transferred emergently.

METHODS

We carried out a retrospective review of facility care records from 20 LTCF in Hyogo, Japan. The participants were 169 LTCF residents with episodes of transfer to emergency hospitalization facilities during a 3-month period. We determined specific CDI variables by interviewing experienced LTCF caregivers, and then carried out a principal component analysis to determine the major parameter set. The generated components were incorporated into a regression model to investigate the association with hospitalization.

RESULTS

The mean age was 87.9 ± 6.5 years, 68% were women and 28% of transfers resulted in hospitalization. The interview procedure identified 12 specific CDI variables, and the principal component analysis generated five distinct components: "change in feeding," "change in emotion," "disengaged or listless gaze," "decrease in eye reactivity" and "change in movement." By multivariate logistic regression, hospitalization was associated with "decrease in eye reactivity" (adjusted OR 1.78, 95% CI 1.07-2.97) and poor vital signs (adjusted OR 2.84, 95% CI 1.15-6.98), but not with body temperature (adjusted OR 1.29, 95% CI 0.52-3.21).

CONCLUSIONS

The CDI might reflect underlying illness severity beyond quantitative physical findings. Once the CDI can be appropriately validated, quantified and linked to physical findings, it could be used by caregivers for daily resident assessments and as a practical triage tool in emergency situations. Geriatr Gerontol Int 2016; 16: 612-617.

The cost-effectiveness of the decision to hospitalize nursing home residents with advanced dementia

CONTEXT

Nursing home (NH) residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve quality of life. Cost-effectiveness analyses of decisions to hospitalize these residents have not been reported.

OBJECTIVES

To estimate the cost-effectiveness of 1) not having a do-not-hospitalize (DNH) order and 2) hospitalization for suspected pneumonia in NH residents with advanced dementia.

METHODS

NH residents from 22 NHs in the Boston area were followed in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study conducted between February 2003 and February 2009. We conducted cost-effectiveness analyses of aggressive treatment strategies for advanced dementia residents living in NHs when they suffer from acute illness. Primary outcome measures included quality-adjusted life days (QALD) and quality-adjusted life years, Medicare expenditures, and incremental net benefits (INBs) over 15 months.

RESULTS

Compared with a less aggressive strategy of avoiding hospital transfer (i.e., having DNH orders), the strategy of hospitalization was associated with an incremental increase in Medicare expenditures of $5972 and an incremental gain in quality-adjusted survival of 3.7 QALD. Hospitalization for pneumonia was associated with an incremental increase in Medicare expenditures of $3697 and an incremental reduction in quality-adjusted survival of 9.7 QALD. At a willingness-to-pay level of $100,000/quality-adjusted life years, the INBs of the more aggressive treatment strategies were negative and, therefore, not cost effective (INB for not having a DNH order, -$4958 and INB for hospital transfer for pneumonia, -$6355).

CONCLUSION

Treatment strategies favoring hospitalization for NH residents with advanced dementia are not cost effective.

Skilled nursing facility admissions of nursing home residents with advanced dementia

OBJECTIVES

To describe the extent to which hospitalized nursing home (NH) residents with advanced dementia were admitted to a skilled nursing facility (SNF) after a qualifying hospitalization and to identify resident and nursing home characteristics associated with a greater likelihood of SNF admissions.

DESIGN

Cohort study using data from the Minimum Data Set, Medicare claims, and the On-line Survey Certification of Automated Records.

SETTING

United States, 2000-2006.

PARTICIPANTS

Nursing home residents with advanced dementia aged 65 and older with a 3-day hospitalization (N = 4,177).

MEASUREMENTS

The likelihood of SNF admission after hospitalization was calculated. Resident and nursing home factors associated with SNF admission were identified using hierarchical multivariable logistic regression.

RESULTS

Sixty-one percent of residents with advanced dementia were admitted to a SNF after their hospitalization. Percutaneous endoscopic gastrostomy (PEG) tube placement during hospitalization was strongly associated with SNF admission (adjusted odds ratio (AOR) = 2.31, 95% confidence interval (CI) = 1.85-2.88), as was better functional status (AOR = 1.21, 95% CI = 1.05-1.38). The presence of diabetes mellitus was associated with lower likelihood of SNF admission (AOR = 0.85, 95% CI = 0.73-0.99). Facility features significantly associated with SNF admission included more than 100 beds (AOR = 1.25, 95% CI = 1.07-1.46), being part of a chain (AOR = 1.31, 95% CI = 1.14-1.50), urban location (AOR = 1.21, 95% CI = 1.03-1.41), and for-profit status (AOR = 1.28, 95% CI = 1.09-1.51).

CONCLUSION

The majority of nursing home residents with advanced dementia are admitted to SNFs after a qualifying hospitalization. SNF admission is strongly associated with PEG tube insertion during hospitalization and with nursing home factors. Efforts to optimize appropriate use of SNF services in individuals with advanced dementia should focus on these factors.

Hospital transfers of nursing home residents with advanced dementia

OBJECTIVES

To describe diagnoses and factors associated with hospital transfer in nursing home (NH) residents with advanced dementia.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston, Massachusetts-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia.

MEASUREMENTS

Data were collected quarterly for up to 18 months. Data regarding transfers were collected with regard to hospitalization or emergency department (ED) visit, diagnosis, and duration of inpatient admission. Information on the occurrence of any acute medical event (pneumonia, febrile episode, or other acute illness) in the prior 90 days was obtained quarterly. Logistic regression conducted at the level of the acute medical event identified characteristics associated with hospital transfer.

RESULTS

The entire cohort experienced 74 hospitalizations and 60 ED visits. Suspected infections were the most common reason for hospitalization (44, 59%), most frequently attributable to a respiratory source (30, 41%). Feeding tube-related complications accounted for 47% of ED visits. In adjusted analysis conducted on acute medical events, younger resident age, event type (pneumonia or other event vs febrile episode), chronic obstructive pulmonary disease, and the lack of a do-not-hospitalize (DNH) order (adjusted odds ratio = 5.22, 95% confidence interval = 2.31-11.79) were associated with hospital transfer.

CONCLUSION

The majority of hospitalizations of NH residents with advanced dementia were due to infections and thus were potentially avoidable, because infections are often treatable in the NH. Feeding tube-related complications accounted for almost half of all ED visits, representing a common but underrecognized burden of this intervention. Advance care planning in the form of a DNH order was the only identified modifiable factor associated with avoiding hospitalization.

Presentation, etiology and outcome of pneumonia in younger nursing home residents

OBJECTIVE

Nursing home-acquired pneumonia characteristically affects elderly patients with multiple comorbidities; it is associated with multidrug-resistant (MDR) pathogens and a high mortality. We studied the specific impact of age on the presentation, etiology and outcome of patients with NHAP.

METHODS

Data from the prospective multicenter CAPNETZ database were used for a comparison of the hospitalized younger nursing home residents with pneumonia to those aged ≥ 65 years as regards clinical presentation, comorbidity, severity at presentation, etiology, and outcome.

RESULTS

Amongst 618 patients with NHAP, 16% of patients (n = 100) were aged; 65 years. Comorbidity was present in most patients with NHAP but the pattern of comorbidity differed significantly. The rate of potential MDR pathogens was low among both age groups (together around 5%). According to the CRB-65 score, NHAP presentation was less severe in the younger patients. Short- and long-term mortality was twice as low in the younger patients with rates of 12.9% vs 26.6%, and 24.3% vs 43.8%, p = 0.014 and 0.002), respectively. In contrast, the usage of mechanical ventilation was more than two-fold higher (12% vs 5%) (p = 0.008) in younger patients. Antimicrobial treatment strategies did not account for different outcomes.

CONCLUSIONS

A considerable proportion of patients with NHAP are: 65 years of age. They differ from older patients in terms of clinical presentation, frequency and type of comorbidity, as well as outcome. NHAP is a heterogeneous entity, with age and comorbidity as the main determinant of NHAP characteristics.

Residential and nursing homes: how can they meet the challenge of an aging population?

A rapidly aging society presents important challenges to care homes. Faced with increasingly elderly residents and progressively more complex clinical and social care needs, nursing and residential homes will have to address a number of issues. These include: how to maintain residents’ quality of life as well as quality of care; how to integrate health and social care provision; how best to manage their interface with hospitals in order to prevent avoidable hospitalizations and facilitate early discharges; and how to utilize new technology in a cost-effective manner. This review examines evidence from across the world on how care home placements can evolve to meet these challenges, with discussion largely adopting a UK perspective. The evidence on innovative ways of working to achieve such aims is growing, although slowly. The potential for new technologies to maintain quality and contain costs is significantly under-developed. More research is now needed.

End-of-life transitions among nursing home residents with cognitive issues

BACKGROUND

Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment.

METHODS

To examine health care transitions among Medicare decedents with advanced cognitive and functional impairment who were nursing home residents 120 days before death, we linked nationwide data from the Medicare Minimum Data Set and claims files from 2000 through 2007. We defined patterns of transition as burdensome if they occurred in the last 3 days of life, if there was a lack of continuity in nursing homes after hospitalization in the last 90 days of life, or if there were multiple hospitalizations in the last 90 days of life. We also considered various factors explaining variation in these rates of burdensome transition. We examined whether there was an association between regional rates of burdensome transition and the likelihood of feeding-tube insertion, hospitalization in an intensive care unit (ICU) in the last month of life, the presence of a stage IV decubitus ulcer, and hospice enrollment in the last 3 days of life.

RESULTS

Among 474,829 nursing home decedents, 19.0% had at least one burdensome transition (range, 2.1% in Alaska to 37.5% in Louisiana). In adjusted analyses, blacks, Hispanics, and those without an advance directive were at increased risk. Nursing home residents in regions in the highest quintile of burdensome transitions (as compared with those in the lowest quintile) were significantly more likely to have a feeding tube (adjusted risk ratio, 3.38), have spent time in an ICU in the last month of life (adjusted risk ratio, 2.10), have a stage IV decubitus ulcer (adjusted risk ratio, 2.28), or have had a late enrollment in hospice (adjusted risk ratio, 1.17).

CONCLUSIONS

Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care.

Pneumonia in the long-term resident

Pneumonia in the long-term resident is common. It is associated with high morbidity and mortality. However, diagnosis and management of pneumonia in long-term care residents is challenging. This article provides an overview of the epidemiology, pathophysiology, diagnostic challenges, and management recommendations for pneumonia in this setting.

Medicare expenditures among nursing home residents with advanced dementia

BACKGROUND

Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, tube feeding) that may be of limited clinical benefit. To our knowledge, Medicare expenditures have not been extensively described in this population.

METHODS

Nursing home residents with advanced dementia in 22 facilities (N = 323) were followed up for 18 months. Clinical and health services use data were collected every 90 days. Medicare expenditures were described. Multivariate analysis was used to identify factors associated with total 90-day expenditures for (1) all Medicare services and (2) all Medicare services excluding hospice.

RESULTS

Over an 18-month period, total mean Medicare expenditures were $2303 per 90 days but were highly skewed; expenditures were less than $500 for 77.1% of the 90-day assessment periods and more than $12,000 for 5.5% of these periods. The largest proportion of Medicare expenditures were for hospitalizations (30.2%) and hospice (45.6%). Among decedents (n = 177), mean Medicare expenditures increased by 65% in each of the last 4 quarters before death owing to an increase in both acute care and hospice. After multivariable adjustment, not living in a special care dementia unit was a modifiable factor associated with higher total expenditures for all Medicare services. Lack of a do-not-hospitalize order, tube feeding, and not living in a special care unit were associated with higher nonhospice Medicare expenditures.

CONCLUSIONS

Medicare expenditures among nursing home residents with advanced dementia vary substantially. Hospitalizations and hospice account for most spending. Strategies that promote high-quality palliative care may shift expenditures away from aggressive treatments for these patients at the end of life.

Hospitalizations in nursing homes: does payer source matter? Evidence from New York State

The objective of this study was to examine the reasons for different hospitalization rates between Medicaid and private-pay nursing home residents-to disentangle within-facility differences from across-facility variations in hospitalizations between these two types of residents. Multiple data sources (2003) for New York State were linked. Hospitalization was the dependent variable. Individual payer status was the main independent variable. Facilities were stratified into four groups by ownership status and bed-hold payment eligibility. We found both within-facility (Medicaid residents were more likely to be hospitalized than private-pay residents within a facility) and across-facility differences (facilities with a higher concentration of Medicaid residents were more likely to hospitalize their residents) controlling for individual and facility characteristics. The magnitude of within-facility differences varied with facility ownership and bed-hold eligibility. To reduce hospitalizations of Medicaid residents and to improve both quality of care and costs, policymakers may need to align Medicaid's and Medicare's incentives.

A multifaceted intervention to implement guidelines did not affect hospitalization rates for nursing home-acquired pneumonia

OBJECTIVE

Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home-acquired pneumonia (NHAP) affected hospitalization rates.

DESIGN

Quasi-experimental, mixed-methods, multifaceted, unblinded intervention trial.

SETTING

Sixteen nursing homes (NHs) from 1 corporation: 8 in metropolitan Denver, CO; 8 in Kansas and Missouri during 3 influenza seasons, October to April 2004 to 2007.

PARTICIPANTS

Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI); NH staff and physicians were eligible.

INTERVENTION

Multifaceted, including academic detailing to clinicians, within-facility nurse change agent, financial incentives, and nursing education.

MEASUREMENTS

Subjects' NH medical records were reviewed for resident characteristics, disease severity, and care processes. Bivariate analysis compared hospitalization rates for subjects with stable and unstable vital signs between intervention and control NHs and time periods. Qualitative interviews were analyzed using content coding.

RESULTS

Hospitalization rates for stable residents in both NH groups remained low throughout the study. Few critically ill subjects in the intervention NHs were hospitalized in either the baseline or intervention period. In control NHs, 8.7% of subjects with unstable vital signs were hospitalized during the baseline and 33% in intervention year 2, but the difference was not statistically significant (P = .10). Interviews with nursing staff and leadership confirmed there were significant pressures for, and enablers of, avoiding hospitalization for treatment of acute infections.

CONCLUSIONS

Secular pressures to avoid hospitalization and the challenges of reaching NH physicians via academic detailing are likely responsible for the lack of intervention effect on hospitalization rates for critically ill NH residents.

Physicians' attitudes toward guidelines for the treatment of hospitalized nursing home-acquired pneumonia

OBJECTIVES

To assess physician awareness, attitudes, and barriers toward the 2005 American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines for the treatment of hospitalized nursing home-acquired pneumonia (NHAP).

METHODS

We conducted a cross-sectional survey of 522 health care providers. The survey assessed the practice setting characteristics, physicians' attitudes, and reported awareness of the 2005 ATS/IDSA guidelines. Factor analysis was conducted to identify scales of variables, and a reliability analysis was performed to verify the reliability of the identified scales.

RESULTS

Three hundred and ten completed the survey. Most responders (88%) reported familiarity with the practice guidelines in their field, but less than half were familiar with the ATS/IDSA NHAP guidelines. Although attitude scores regarding clinical practice guidelines did not differ significantly among various disciplines (P = .63), there were 2 characteristics that correlated with positive attitudes toward the 2005 ATS/IDSA guidelines in a multivariate analysis: being a pulmonary specialist (P ≤ .001) and time spent on CME activity per month (P = .03). The main barriers to the 2005 ATS/IDSA guidelines implementation were lack of awareness, concerns about practicality of using the recommended regimens, increased cost, lack of documented improved outcomes, and potential conflict with other guidelines.

CONCLUSION

The study indicates low levels of awareness with the 2005 ATS/IDSA guidelines for treatment of hospitalized NHAP. Targeted intervention efforts including outcome assessment and cost-effective analysis may be necessary to improve adherence with the proposed guidelines.

Validation of the Minimum Data Set in identifying hospitalization events and payment source

OBJECTIVES

To evaluate the accuracy of the Minimum Data Set (MDS) in identifying hospitalization events and payment source among nursing home residents.

RESEARCH DESIGN

The 2003 MDS, Medicare Provider Analysis and Review File (MedPAR), Medicare denominator file, Medicaid Analytical Extract (MAX) long-term care file, and MAX personal summary file for 4 states (California, Ohio, New York, and Texas) were obtained and merged.

SETTING

All Medicare/Medicaid-certified nursing ho-mes in these 4 states during 2003.

PARTICIPANTS

All nursing home residents who were eligible for Medicare. Medicare or Medicaid managed care enrollees were excluded.

MEASUREMENTS

Using the identification by linking the MDS and claims data as the "gold standard," we calculated false negative and false positive error rates of the MDS in identifying hospitalization events and payment source.

RESULTS

As for the accuracy of the MDS in identifying hospitalization events, the false negative error rates ranged from 6.8% to 19.5% and the false positive error rates were between 12.0% and 15.7%, depending on the state. With regard to the identification of Medicare payment source, the MDS had a low false negative rate (varying from 0.4% to 1.1%), and a relatively high false positive rate (ranging from 6.1% to 14.9%). The MDS alone did not seem to be a sufficient source for identification of Medicaid payment source (false negative rate ranging from 11.0% to 55.3%).

CONCLUSIONS

The accuracy of the MDS in identifying hospitalizations and payment sources varies across the study states, and should be evaluated carefully with regard to the intended uses of the data.

Prognosis is important in decisionmaking in Dutch nursing home patients with dementia and pneumonia

OBJECTIVE

To explore how physicians treating nursing home residents with dementia and pneumonia in the Netherlands consider prognosis in their treatment decision.

METHODS

Survey study with data collected between July 2006 and March 2008. Physicians (n = 69) from 54 nursing homes in the Netherlands completed a questionnaire on symptoms, treatment, and prognosis for their next dementia patient newly diagnosed with pneumonia. They were also asked a general question regarding withholding antibiotic treatment and prognosis. Outcome was assessed at least two months afterwards. Two-week mortality risk if treated with antibiotics was calculated with a validated prognostic score.

RESULTS

The patients not treated with antibiotics had high (92%) actual 2-week mortality while only 12% of patients treated with antibiotics died. Physicians believed that mortality risk was high in the untreated group and would have been only slightly lower if treated with antibiotics (mean estimated risk 73%), which was higher than predicted from the risk score (42%). In general, three-quarters of physicians considered withholding antibiotics appropriate for mortality risks between 75% and 90%.

CONCLUSIONS

Prognosis is an important consideration when Dutch nursing home physicians make antibiotic treatment decisions for patients with dementia and pneumonia. This suggests they prefer not to treat with antibiotics when to do so is probably futile. Physicians in other countries may hold different views on futility, which should be addressed in larger, cross-national comparative studies.

Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America

Residents of long‐term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one‐half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on‐site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.

Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America

Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.

Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America

Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.

In-reach specialist nursing teams for residential care homes: uptake of services, impact on care provision and cost-effectiveness

BACKGROUND

A joint NHS-Local Authority initiative in England designed to provide a dedicated nursing and physiotherapy in-reach team (IRT) to four residential care homes has been evaluated. The IRT supported 131 residents and maintained 15 'virtual' beds for specialist nursing in these care homes.

METHODS

Data captured prospectively (July 2005 to June 2007) included: numbers of referrals; reason for referral; outcome (e.g. admission to IRT bed, short-term IRT support); length of stay in IRT; prevented hospital admissions; early hospital discharges; avoided nursing home transfers; and detection of unrecognised illnesses. An economic analysis was undertaken.

RESULTS

733 referrals were made during the 2 years (range 0.5 to 13.0 per resident per annum) resulting in a total of 6,528 visits. Two thirds of referrals aimed at maintaining the resident's independence in the care home. According to expert panel assessment, 197 hospital admissions were averted over the period; 20 early discharges facilitated; and 28 resident transfers to a nursing home prevented. Detection of previously unrecognised illnesses accounted for a high number of visits. Investment in IRT equalled 44.38 pounds per resident per week. Savings through reduced hospital admissions, early discharges, delayed transfers to nursing homes, and identification of previously unrecognised illnesses are conservatively estimated to produce a final reduction in care cost of 6.33 pounds per resident per week. A sensitivity analysis indicates this figure might range from a weekly overall saving of 36.90 pounds per resident to a 'worst case' estimate of 2.70 pounds extra expenditure per resident per week.Evaluation early in implementation may underestimate some cost-saving activities and greater savings may emerge over a longer time period. Similarly, IRT costs may reduce over time due to the potential for refinement of team without major loss in effectiveness.

CONCLUSION

Introduction of a specialist nursing in-reach team for residential homes is at least cost neutral and, in all probability, cost saving. Further benefits include development of new skills in the care home workforce and enhanced quality of care. Residents are enabled to stay in familiar surroundings rather than unnecessarily spending time in hospital or being transferred to a higher dependency nursing home setting.

Benefits and pitfalls of pooling datasets from comparable observational studies: combining US and Dutch nursing home studies

Different research groups sometimes carry out comparable studies. Combining the data can make it possible to address additional research questions, particularly for small observational studies such as those frequently seen in palliative care research. We present a systematic approach to pool individual subject data from observational studies that addresses differences in research design, illustrating the approach with two prospective observational studies on treatment and outcomes of lower respiratory tract infection in US and Dutch nursing home residents. Benefits of pooling individual subject data include enhanced statistical power, the ability to compare outcomes and validate models across sites or settings, and opportunities to develop new measures. In our pooled dataset, we were able to evaluate treatments and end-of-life decisions for comparable patients across settings, which suggested opportunities to improve care. In addition, greater variation in participants and treatments in the combined dataset allowed for subgroup analyses and interaction hypotheses, but required more complex analytic methods. Pitfalls included the large amount of time required for equating study procedures and variables and the need for additional funding.

Medicare expenditures for nursing home residents triaged to nursing home or hospital for acute infection

OBJECTIVES

To compare Medicare payments of nursing home residents triaged to nursing home with those of nursing home residents triaged to the hospital for acute infection care.

DESIGN

Observational study with propensity score matching.

SETTING

Fifty-nine nursing homes in Maryland.

PARTICIPANTS

Two thousand two hundred eighty-five individuals admitted to the 59 nursing homes and followed between 1992 and 1997.

MEASUREMENTS

Demographic and clinical data were obtained from interviews and medical record review and linked to Medicare payment records. Incident infection was ascertained according to medical record review for new infectious diagnoses or prescription of antibiotics. Hospital triage was defined as hospital transfer within 3 days of infection onset. Hospital triage patients were paired with similar nursing home triage patients using propensity score matching. Medicare expenditures for triage groups were compared in 1997 dollars.

RESULTS

Of 3,618 infection cases, 28% were genitourinary infections, 20% skin, 14% upper respiratory, 12% lower respiratory, 4% gastrointestinal, and 2% bloodstream. Two hundred fifty-six pairs of hospital and nursing home triage cases fulfilled matching criteria. Mean Medicare payments+/-standard deviation were $5,202+/-7,310 and $996+/-2,475 per case in the hospital and nursing home triage groups, respectively, for a mean difference of $4,206 (95% confidence interval=$3,260-5,151). Mean payments per case in the hospital triage group were $3,628 higher in inpatient expenditures, $482 higher in physician visit expenditures, $161 higher in emergency department expenditures, and $147 higher in skilled nursing day expenditures.

CONCLUSION

Per-case Medicare expenditures are higher with hospital triage than for nursing home triage for nursing home residents with acute infection. This result may be used to estimate cost savings to Medicare of interventions designed to reduce hospital use by nursing home residents.

Predictors of nursing home hospitalization: a review of the literature

Hospitalization of nursing home residents is costly and potentially exposes residents to iatrogenic disease and psychological harm. This article critically reviews the association between the decision to hospitalize and factors related to the residents' welfare and preferences, the providers' attitudes, and the financial implications of hospitalization. Regarding the resident's welfare, factors associated with hospitalization included sociodemographics, health characteristics, nurse staffing, the presence of ancillary services, and the use of hospices. Patient preferences (e.g., advance directives) and provider attitudes (e.g., overburdening of staff) were also associated with increased hospitalization. Finally, financial variables related to hospitalization included nursing home ownership status and state Medicaid policies, such as nursing home payment rates and bed-hold requirements. Most studies relied on potentially confounded research designs, which leave open the issue of selection bias. Nevertheless, the existing literature asserts that nursing home hospitalizations are frequent, often preventable, and related to facility practices and state Medicaid policies.

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.

Treatment strategy and risk of functional decline and mortality after nursing-home acquired lower respiratory tract infection: two prospective studies in residents with dementia

BACKGROUND

Although lower respiratory tract infections (LRI) cause considerable morbidity and mortality among nursing home residents with dementia, the effects of care and treatment are largely unknown. Few large prospective studies have been conducted.

METHODS

We pooled data from two large prospective cohort studies in 61 Dutch nursing homes and 36 nursing homes in the state of Missouri, United States. We included 551 US residents and 381 Dutch residents with dementia and LRI. Main outcome measures were 3-month mortality and decline in activities of daily living (ADL) function after 3 months compared with pre-illness status. Using multivariable multinomial logistic regression to control for confounding, we assessed associations of restraint use and antibiotic type (oral compared with parenteral), with outcomes of lower respiratory tract infection (LRI). Survival without ADL decline was the reference category.

RESULTS

After multivariable adjustment, restraint use was associated with ADL decline (OR 1.9, 95% CI 1.1-3.3). Oral antibiotics were not associated with 3-month mortality (OR 0.83; 95% CI 0.56-1.2). Severe dementia was the strongest independent predictor of decline; mortality was most strongly associated with male gender.

CONCLUSIONS

Among Dutch and US nursing home residents with dementia and LRI, restrained residents suffered more decline. Parenteral antibiotic treatment was not associated with better outcome in residents at low to moderate risk of mortality. Aggressive treatment strategies may provide little benefit for the majority of nursing home residents with dementia and LRI.

Should I hospitalize my resident with nursing home-acquired pneumonia?

INTRODUCTION

Pneumonia is the leading cause of mortality, morbidity, and transfers to acute care facilities among residents of nursing homes. With the expected growth of the nursing home population over the next 30 years, the annual incidence of nursing home-acquired pneumonia (NHAP) is expected to reach 1.9 million cases. Yet there is growing evidence to suggest that the transfer of nursing home residents to hospitals with NHAP results in little to no improvement in overall mortality or morbidity when compared with residents treated in the nursing home. Furthermore, recent evidence suggests that nursing home residents admitted to hospitals may be at greater risk for functional decline, delirium, and pressure ulcer formation following hospitalization. The author therefore performed a comprehensive review of the literature to consider the salient issues confronting a clinician faced with the question of whether to transfer a nursing home resident diagnosed with pneumonia to an acute care facility.

METHODOLOGY

A structured literature search was performed relating to the diagnosis, treatment, and triage of residents with nursing home pneumonia. Relevant key words used to conduct this search included: pneumonia, long-term care facility, nursing home, nursing home-acquired pneumonia, triage, treatment, and hospitalization. References in English dated from 1966 to the present day were considered.

RESULTS

One prospective observational study and 2 retrospective, case control studies have directly compared the 30-day mortality rates of residents with NHAP who are hospitalized versus those who are treated in the nursing home. A second, prospective, observational study evaluated the mortality rate in residents with any form of infection who were transferred to acute care hospitals. These studies all suggest that mortality rates are similar or reduced when residents are treated in the nursing home. Studies also suggest that considerable cost savings can be incurred when residents are treated in the nursing home. Additional literature reviews were conducted to evaluate important factors that need to be considered before making triage decisions on nursing home residents diagnosed with pneumonia. These factors include the ease of making the diagnosis of NHAP, the availability and use of antibiotics, relevant cost issues, and barriers to providing adequate care in the nursing home environment.

CONCLUSION

There is growing evidence to suggest that hospitalization for residents with NHAP is not required and may result in increased cost, morbidity, and mortality. To date, studies show that residents may benefit from hospitalization if their respiratory rate is over 40. Otherwise, if appropriate treatment can be initiated expeditiously in the nursing home, resident mortality and morbidity may decrease. Numerous barriers to treating acutely ill residents in the nursing home exist, including a difficulty in obtaining antibiotics quickly, inadequate staffing, and poor documentation of a resident's wishes for hospitalization. More studies need to be conducted to further identify these barriers to nursing home care.

Nursing Home–Associated Pneumonia

Nursing home-associated pneumonia (NHAP) is associated with considerable morbidity and mortality. The etiology of NHAP continues to be debated and has influenced treatment guideline recommendations. Diagnosis may not be straightforward but at least one respiratory symptom usually is present and the presence of hypoxemia is a key finding. Treatment recommendations vary depending on the organisms believed the predominant cause of NHAP. Pneumococcal and influenza vaccination remain the most important methods for prevention of NHAP at present.

Decisions to forgo hospitalization in advanced dementia: a nationwide study

OBJECTIVES

To examine the prevalence and factors associated with decisions to forgo hospitalization in nursing home (NH) residents with advanced dementia.

DESIGN

Cross-sectional study.

SETTING

All Medicare- and Medicaid-certified NHs within the 48 contiguous U.S. states.

PARTICIPANTS

NH residents with advanced dementia were identified using Minimum Data Set (MDS) assessments completed close to April 1, 2000 (N=91,521).

MEASUREMENTS

Multilevel, multivariate logistic regression identified factors independently associated with having a do-not-hospitalize (DNH) directive. Independent variables included subject characteristics (MDS), facility factors (On-line Survey of Certification of Automated Records), and hospital referral region (HRR) features (Dartmouth Atlas).

RESULTS

Nationwide, 7.1% (n=6,518) residents with advanced dementia had DNH orders (range 0.7% in Oklahoma to 25.9% in Rhode Island). Resident characteristics associated with having a DNH order were older age, white, living will, durable power of attorney for health care, and total functional dependence. Controlling for these factors, DNH orders were more likely in residents of facilities with the following features: not part of a chain, urban location, special care dementia unit, fewer black residents, nurse practitioner or physician assistant on staff, higher staffing ratios, and location in HRRs with fewer intensive care unit admissions during terminal hospitalizations.

CONCLUSION

Directives to forgo hospitalization for U.S. NH residents with advanced dementia are uncommon and are associated with the organizational features of the facilities caring for them and the intensity of end-of-life care practiced in the region, as well as individual resident characteristics.