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Turbow SD, Perkins MM, Vaughan CP, Klemensen T, Culler SD, Rask KJ, Clevenger CK, Ali MK. Fragmented Readmissions From a Nursing Facility in Medicare Beneficiaries. J Appl Gerontol 2024:7334648241254282. [PMID: 38798097 DOI: 10.1177/07334648241254282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Over one-third of Medicare beneficiaries discharged to nursing facilities require readmission. When those readmissions are to a different hospital than the original admission, or "fragmented readmissions," they carry increased risks of mortality and subsequent readmissions. This study examines whether Medicare beneficiaries readmitted from a nursing facility are more likely to have a fragmented readmission than beneficiaries readmitted from home among a 2018 cohort of Medicare beneficiaries, and examined whether this association was affected by a diagnosis of Alzheimer's Disease (AD). In fully adjusted models, readmissions from a nursing facility were 19% more likely to be fragmented (AOR 1.19, 95% CI 1.16, 1.22); this association was not affected by a diagnosis of AD. These results suggest that readmission from nursing facilities may contribute to care fragmentation for older adults, underscoring it as a potentially modifiable pre-hospital risk factor for fragmented readmissions.
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Affiliation(s)
- Sara D Turbow
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Family & Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Molly M Perkins
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Camille P Vaughan
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Veterans Affairs Birmingham/Atlanta Geriatric Research Education and Clinical Center, Atlanta, GA, USA
| | - Terry Klemensen
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven D Culler
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | | | - Mohammed K Ali
- Department of Family & Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Browne B, Ali K, Ford E, Tabet N. Determinants of hospital readmissions in older people with dementia: a narrative review. BMC Geriatr 2024; 24:336. [PMID: 38609878 PMCID: PMC11015733 DOI: 10.1186/s12877-024-04905-6] [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: 10/27/2023] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
INTRODUCTION Over 50% of hospitalised older people with dementia have multimorbidity, and are at an increased risk of hospital readmissions within 30 days of their discharge. Between 20-40% of these readmissions may be preventable. Current research focuses on the physical causes of hospital readmissions. However, older people with dementia have additional psychosocial factors that are likely to increase their risk of readmissions. This narrative review aimed to identify psychosocial determinants of hospital readmissions, within the context of known physical factors. METHODS Electronic databases MEDLINE, EMBASE, CINAHL and PsychInfo were searched from inception until July 2022 and followed up in February 2024. Quantitative and qualitative studies in English including adults aged 65 years and over with dementia, their care workers and informal carers were considered if they investigated hospital readmissions. An inductive approach was adopted to map the determinants of readmissions. Identified themes were described as narrative categories. RESULTS Seventeen studies including 7,194,878 participants met our inclusion criteria from a total of 6369 articles. Sixteen quantitative studies included observational cohort and randomised controlled trial designs, and one study was qualitative. Ten studies were based in the USA, and one study each from Taiwan, Australia, Canada, Sweden, Japan, Denmark, and The Netherlands. Large hospital and insurance records provided data on over 2 million patients in one American study. Physical determinants included reduced mobility and accumulation of long-term conditions. Psychosocial determinants included inadequate hospital discharge planning, limited interdisciplinary collaboration, socioeconomic inequalities among ethnic minorities, and behavioural and psychological symptoms. Other important psychosocial factors such as loneliness, poverty and mental well-being, were not included in the studies. CONCLUSION Poorly defined roles and responsibilities of health and social care professionals and poor communication during care transitions, increase the risk of readmission in older people with dementia. These identified psychosocial determinants are likely to significantly contribute to readmissions. However, future research should focus on the understanding of the interaction between a host of psychosocial and physical determinants, and multidisciplinary interventions across care settings to reduce hospital readmissions.
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Affiliation(s)
- Bria Browne
- Centre for Dementia Studies, Brighton and Sussex Medical School, The University of Sussex Brighton, Brighton, UK.
| | - Khalid Ali
- Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Elderly Care and Stroke Medicine, University Hospitals Sussex NHS Trust, Brighton, UK
| | - Elizabeth Ford
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Naji Tabet
- Centre for Dementia Studies, Brighton and Sussex Medical School, The University of Sussex Brighton, Brighton, UK
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Doumat G, Daher D, Itani M, Abdouni L, El Asmar K, Assaf G. The effect of polypharmacy on healthcare services utilization in older adults with comorbidities: a retrospective cohort study. BMC PRIMARY CARE 2023; 24:120. [PMID: 37237338 DOI: 10.1186/s12875-023-02070-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/17/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Older adults are more prone to increasing comorbidities and polypharmacy. Polypharmacy is associated with inappropriate prescribing and an increased risk of adverse effects. This study examined the effect of polypharmacy in older adults on healthcare services utilization (HSU). It also explored the impact of different drug classes of polypharmacy including psychotropic, antihypertensive, and antidiabetic polypharmacy on HSU. METHODS This is a retrospective cohort study. Community-dwelling older adults aged ≥ 65 years were selected from the primary care patient cohort database of the ambulatory clinics of the Department of Family Medicine at the American University of Beirut Medical Center. Concomitant use of 5 or more prescription medications was considered polypharmacy. Demographics, Charlson Comorbidity index (CCI), and HSU outcomes, including the rate of all-cause emergency department (ED) visits, rate of all-cause hospitalization, rate of ED visits for pneumonia, rate of hospitalization for pneumonia, and mortality were collected. Binomial logistic regression models were used to predict the rates of HSU outcomes. RESULTS A total of 496 patients were analyzed. Comorbidities were present in all patients, with 22.8% (113) of patients having mild to moderate comorbidity and 77.2% (383) of patients having severe comorbidity. Patients with polypharmacy were more likely to have severe comorbidity compared to patients with no polypharmacy (72.3% vs. 27.7%, p = 0.001). Patients with polypharmacy were more likely to visit the ED for all causes as compared to patients without polypharmacy (40.6% vs. 31.4%, p = 0.05), and had a significantly higher rate of all-cause hospitalization (adjusted odds ratio aOR 1.66, 95 CI = 1.08-2.56, p = 0.022). Patients with psychotropic polypharmacy were more likely to be hospitalized due to pneumonia (crude odds ratio cOR 2.37, 95 CI = 1.03-5.46, p = 0.043), and to visit ED for Pneumonia (cOR 2.31, 95 CI = 1.00-5.31, p = 0.049). The association lost significance after adjustment. CONCLUSIONS The increasing prevalence of polypharmacy amongst the geriatric population with comorbidity is associated with an increase in HSU outcomes. As such, frequent medication revisions in a holistic, multi-disciplinary approach are needed.
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Affiliation(s)
- George Doumat
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Darine Daher
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mira Itani
- Department of Family Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Lina Abdouni
- Department of Family Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Khalil El Asmar
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Georges Assaf
- Department of Family Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
- Division of Academic Internal Medicine & Geriatrics, The University of Illinois at Chicago, Chicago, USA.
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Potter AJ, Wright B, Akiyama J, Stehlin GG, Trivedi AN, Wolinsky FD. Primary care patterns among dual eligibles with Alzheimer's disease and related dementias. J Am Geriatr Soc 2023; 71:1259-1266. [PMID: 36585893 PMCID: PMC10089966 DOI: 10.1111/jgs.18166] [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: 08/08/2022] [Revised: 10/26/2022] [Accepted: 11/20/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Primary care is essential for persons with Alzheimer's disease and related dementias (ADRD). Prior research suggests that the propensity to provide high-quality, continuous primary care varies by provider setting, but the settings used by Medicare-Medicaid dual-eligibles with ADRD have not been described at the population level. METHODS Using 2012-2018 Medicare data, we identified dual-eligibles with ADRD. For each person-year, we identified primary care visits occurring in six settings. We calculated descriptive statistics for beneficiaries with a majority of visits in each setting, and conducted a k-means cluster analysis to determine utilization patterns, using the standardized count of primary care visits in each setting. RESULTS Each year from 2012 to 2018, at least 45.6% of dual-eligibles with ADRD received a majority of their primary care in nursing facilities, while at least 25.2% did so in physician offices. Over time, the share relying on nursing facilities for primary care decreased by 5.2 percentage points, offset by growth in Federally Qualified Health Centers (FQHCs) and miscellaneous settings (2.3 percentage points each). Dual-eligibles relying on nursing facilities had more annual primary care visits (16.1) than those relying on other settings (range: 6.8-10.7 visits). Interpersonal care continuity was also higher in nursing facilities (97.0%) and physician offices (87.9%) than in FQHCs (54.2%), rural health clinics (RHCs, 46.6%), or hospital-based clinics (56.8%). Among dual-eligibles without care continuity, 82.7% were assigned to a cluster with few primary care visits. CONCLUSIONS A trend toward care in different settings likely reflects improved access to patient-centered primary care. Low rates of interpersonal care continuity in FQHCs, RHCs, and physician offices may warrant concern, unless providers in these settings function as a care team. Nonetheless, every healthcare system encounter presents an opportunity to designate a primary care provider for dual-eligibles with ADRD who use little or no primary care.
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Affiliation(s)
- Andrew J. Potter
- Department of Political Science & Criminal Justice, California State University, Chico
| | - Brad Wright
- Department of Family Medicine, UNC-Chapel Hill School of Medicine, Chapel Hill, NC
- Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill, Chapel Hill, NC
| | - Jill Akiyama
- Department of Health Policy and Management, Gillings School of Public Health, UNC-Chapel Hill
| | - Grace G. Stehlin
- Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill, Chapel Hill, NC
| | - Amal N. Trivedi
- Department of Health Services, Policy and Practice, School of Public Health, Brown University
| | - Fredric D. Wolinsky
- Department of Health Management and Policy, College of Public Health, University of Iowa
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Fang YY, Ni JC, Wang Y, Yu JH, Fu LL. Risk factors for hospital readmissions in pneumonia patients: A systematic review and meta-analysis. World J Clin Cases 2022; 10:3787-3800. [PMID: 35647168 PMCID: PMC9100707 DOI: 10.12998/wjcc.v10.i12.3787] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/25/2022] [Accepted: 03/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Factors that are associated with the short-term rehospitalization have been investigated previously in numerous studies. However, the majority of these studies have not produced any conclusive results because of their smaller sample sizes, differences in the definition of pneumonia, joint pooling of the in-hospital and post-discharge deaths and lower generalizability.
AIM To estimate the effect of various risk factors on the rate of hospital readmissions in patients with pneumonia.
METHODS Systematic search was conducted in PubMed Central, EMBASE, MEDLINE, Cochrane library, ScienceDirect and Google Scholar databases and search engines from inception until July 2021. We used the Newcastle Ottawa (NO) scale to assess the quality of published studies. A meta-analysis was carried out with random-effects model and reported pooled odds ratio (OR) with 95% confidence interval (CI).
RESULTS In total, 17 studies with over 3 million participants were included. Majority of the studies had good to satisfactory quality as per NO scale. Male gender (pooled OR = 1.22; 95%CI: 1.16-1.27), cancer (pooled OR = 1.94; 95%CI: 1.61-2.34), heart failure (pooled OR = 1.28; 95%CI: 1.20-1.37), chronic respiratory disease (pooled OR = 1.37; 95%CI: 1.19-1.58), chronic kidney disease (pooled OR = 1.38; 95%CI: 1.23-1.54) and diabetes mellitus (pooled OR = 1.18; 95%CI: 1.08-1.28) had statistically significant association with the hospital readmission rate among pneumonia patients. Sensitivity analysis showed that there was no significant variation in the magnitude or direction of outcome, indicating lack of influence of a single study on the overall pooled estimate.
CONCLUSION Male gender and specific chronic comorbid conditions were found to be significant risk factors for hospital readmission among pneumonia patients. These results may allow clinicians and policymakers to develop better intervention strategies for the patients.
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Affiliation(s)
- Yuan-Yuan Fang
- Department of Geriatrics, Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China
| | - Jian-Chao Ni
- Department of Geriatrics, Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China
| | - Yin Wang
- Department of Internal Medicine, Yuecheng People’s Hospital, Shaoxing 312000, Zhejiang Province, China
| | - Jian-Hong Yu
- Department of Geriatrics, Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China
| | - Ling-Ling Fu
- Department of Respiratory Medicine, Zhuji Affiliated Hospital of Shaoxing University, Zhuji 311800, Zhejiang Province, China
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Knox S, Downer B, Haas A, Ottenbacher KJ. Mobility and Self-Care are Associated With Discharge to Community After Home Health for People With Dementia. J Am Med Dir Assoc 2021; 22:1493-1499.e1. [PMID: 33476569 PMCID: PMC8496773 DOI: 10.1016/j.jamda.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/17/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES A priority health outcome for patients, families, and the Centers for Medicare & Medicaid Services (CMS) is a patient's ability to return home and remain in the community without adverse events following discharge from post-acute care services. Successful discharge to community (DTC) is defined as being discharged to the community and not experiencing a readmission or death within 30 days of discharge. The objective of this study was to determine the association between patient factors and successful DTC after home health for individuals with Alzheimer's disease and related dementias (ADRD). DESIGN This retrospective study derived data from 100% national CMS data files from October 1, 2016, through September 30, 2017. SETTINGS AND PARTICIPANTS Criteria from the Home Health Quality Reporting program were used to identify a cohort of 790,439 Medicare home health beneficiaries, 143,164 (18.0%) with ADRD. MEASURES Successful DTC rates with associated 95% confidence intervals (CIs) were calculated for each patient characteristic. Multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC after home health, by ADRD diagnosis, mobility, self-care, caregiver support, and medication management, adjusted for patient demographics and clinical characteristics. RESULTS Overall, 79.4% of beneficiaries had a successful DTC. Beneficiaries with ADRD had a significantly lower odds of successful DTC than those without ADRD (RR=0.947, 95% CI=0.944-0.950). This association remained significant after adjustment for caregiver support, assistance with medications, independence in mobility, and level of self-care. Greater need for caregiver support, greater need for assistance with medications, greater dependence in mobility, and greater self-care dependence were all associated with decreased risk of successful DTC. CONCLUSIONS AND IMPLICATIONS Older adults with ADRD receiving home health had decreased RR of successful DTC. To have a successful DTC, older adults with ADRD need sufficient support from caregivers and independence in functioning.
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Affiliation(s)
- Sara Knox
- Division of Physical Therapy, Medical University of South Carolina, Charleston, SC, USA.
| | - Brian Downer
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX, USA
| | - Allen Haas
- Department of Preventative Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Kenneth J Ottenbacher
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX, USA
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Janbek J, Frimodt-Møller N, Laursen TM, Waldemar G. Hospital readmissions following infections in dementia: a nationwide and registry-based cohort study. Eur J Neurol 2021; 28:3603-3614. [PMID: 33978303 DOI: 10.1111/ene.14911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION We aimed to investigate readmission risks following infections in dementia, identify the types of infections behind the risks, and highlight the reasons for readmissions. METHODS Acute inpatient hospital admissions for infections in Danish residents were included from 1 January 2000, or age 65 years. Primary outcomes were 7-day readmissions risk ratios (RRs; risk following infection index admissions of people with dementia relative to those without dementia), risks by infection site, and reasons for readmission. Secondary outcomes were 30- and 90-day readmission risks. Competing risk of death was estimated. RESULTS Seven-day readmission RR was increased in all age groups and was highest in the youngest patients (women RR: 1.37, 95% confidence interval [CI] 1.22-1.53; men RR: 1.23, 95% CI 1.12-1.35). RRs decreased with increasing age and longer follow-up. The most notable common readmissions were for infections and dehydration in dementia. CONCLUSIONS We conclude that there is a substantially increased readmission risk in people with dementia than in those without dementia, particularly within 7 days, and for the youngest in the cohort. Readmission risks were higher for infection index admissions than for admissions for causes other than infection, and readmissions were mostly due to infections. Our findings highlight the burden of infections in people with dementia and call for in-depth investigations of determinants related to readmission risks, to inform public policy and identify avenues for interventions that can decrease or prevent potentially avoidable readmissions.
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Affiliation(s)
- Janet Janbek
- Department of Neurology, Danish Dementia Research Centre, Section 8007, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Niels Frimodt-Møller
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Munk Laursen
- Department of Economics and Business Economics, National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus V, Denmark
| | - Gunhild Waldemar
- Department of Neurology, Danish Dementia Research Centre, Section 8007, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Graversen SB, Pedersen HS, Sandbaek A, Foss CH, Palmer VJ, Ribe AR. Dementia and the risk of short-term readmission and mortality after a pneumonia admission. PLoS One 2021; 16:e0246153. [PMID: 33507947 PMCID: PMC7842970 DOI: 10.1371/journal.pone.0246153] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/15/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND At time of discharge after a pneumonia admission, care planning for older persons with dementia is essential. However, care planning is limited by lack of knowledge on the short-term prognosis. AIM To investigate 30-day mortality and readmission after hospital discharge for pneumonia in persons with versus without dementia, and to investigate how these associations vary with age, time since discharge, and medication use. METHODS Using the Danish registries, we investigated 30-day mortality and readmission in persons (+65 years) discharged after pneumonia in 2000-2016 (N = 298,872). Adjusted mortality rate ratios (aMRRs) and incidence rate ratios (aIRRs) were calculated for persons with versus without dementia, and we investigated if these associations varied with use of benzodiazepines, opioids, and antipsychotics, and with age and time since discharge. RESULTS Among 25,948 persons with dementia, 4,524 died and 5,694 were readmitted within 30 days. The risk of 30-day mortality was 129% higher (95% CI 2.21-2.37) in persons with versus without dementia after adjustment for sociodemographic characteristics, admission-related factors, and comorbidities. Further, the highest mortality risk was found in persons with both dementia and use of antipsychotics (aMRR: 3.39, 95% CI 3.19-3.59); 16% of deaths in this group could not be explained by the independent effect of each exposure. In those with dementia, the highest aMRRs were found for the youngest and for the first days after discharge. The risk of 30-day readmission was 7% higher (95% CI 1.04-1.10) in persons with versus without dementia. In those with dementia, the highest aIRRs were found for the first days after discharge. CONCLUSIONS Dementia was associated with higher short-term mortality after pneumonia, especially in users of antipsychotics, and with slightly higher readmission, especially in the first days after discharge. This is essential knowledge in the care planning for persons with dementia who are discharged after a pneumonia admission.
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Affiliation(s)
- Susanne Boel Graversen
- Research Unit for General Practice, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - Annelli Sandbaek
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus, Denmark
| | | | - Victoria Jane Palmer
- The Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
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