1
|
Xue TM, Pan W, Tsumura H, Wei S, Lee C, McConnell ES. Impact of Dementia on Long-Term Hip Fracture Surgery Outcomes: An Electronic Health Record Analysis. J Am Med Dir Assoc 2023; 24:235-241.e2. [PMID: 36525987 DOI: 10.1016/j.jamda.2022.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/03/2022] [Accepted: 11/05/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Older adults with dementia are at higher risk for sustaining hip fracture and their long-term health outcomes after surgery are usually worse than those without dementia. Widespread adoption of electronic health records (EHRs) may allow hospitals to better monitor long-term health outcomes in patients with dementia after hospitalization. This study aimed to (1) estimate how dementia influences discharge location, mortality, and readmission 180 days and 1 year after hip fracture surgery in older adults, and (2) demonstrate the feasibility of using selection-bias reduced EHR data for research and long-term health outcomes monitoring. DESIGN Retrospective observational cohort study using EHRs. SETTING AND PARTICIPANTS A cohort of 1171 patients over age 65 years who had an initial hip fracture surgery between October 2015 and December 2018 was extracted from EHRs of one health system; 376 of these patients had dementia. METHODS Logistic regression was applied to estimate influences of dementia on discharge disposition and Cox proportional hazards model for mortality. The Fine and Gray regression model was used to analyze readmission, accounting for the competing risk of death. To reduce selection bias in EHRs, inverse probability of treatment weighting using propensity scores was implemented before modeling. RESULTS Dementia had significant impacts on all outcomes: being discharged to facilities [odds ratio (OR) = 2.11, 95% confidence interval (CI) 1.19-3.74], 180-day mortality [hazard ratio (HR) = 1.69, 95% CI 1.20-2.38], 1-year mortality (HR = 1.78, 95% CI 1.33-2.38), 180-day readmission (HR = 1.62, 95% CI 1.39-1.89), and 1 year readmission (HR = 1.39, 95% CI 1.21-1.58). CONCLUSIONS AND IMPLICATIONS Dementia was a significant risk factor for worse long-term outcomes. The inverse probability of treatment weighting approach can be used to reduce selection bias in EHR data for research and monitoring long-term health outcomes in the target population. Such monitoring could foster collaborations with post-acute and long-term health care services to improve recovery outcomes in patients with dementia after hip fracture surgery.
Collapse
Affiliation(s)
- Tingzhong Michelle Xue
- Duke University School of Nursing, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA.
| | - Wei Pan
- Duke University School of Nursing, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | - Sijia Wei
- Center for Education in Health Sciences, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Chiyoung Lee
- University of Washington Bothell, School of Nursing and Health Studies, Bothell, WA, USA
| | - Eleanor S McConnell
- Duke University School of Nursing, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA
| |
Collapse
|
2
|
Braun RT, Jung HY, Casalino LP, Myslinski Z, Unruh MA. Association of Private Equity Investment in US Nursing Homes With the Quality and Cost of Care for Long-Stay Residents. JAMA HEALTH FORUM 2021; 2:e213817. [PMID: 35977267 PMCID: PMC8796926 DOI: 10.1001/jamahealthforum.2021.3817] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022] Open
Abstract
Question Is private equity acquisition of nursing homes associated with the quality or cost of care for long-stay nursing home residents? Findings In this cohort study with difference-in-differences analysis of 9864 US nursing homes, including 9632 residents in 302 nursing homes acquired by private equity firms and 249 771 residents in 9562 other for-profit nursing homes without private equity ownership, private equity acquisition of nursing homes was associated with higher costs and increases in emergency department visits and hospitalizations for ambulatory sensitive conditions. Meaning This study suggests that more stringent oversight and reporting on private equity ownership of nursing homes may be warranted. Importance Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. Objective To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. Design, Setting, and Participants In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity–acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Exposure Private equity acquisitions of 302 nursing homes between 2013 and 2017. Main Outcomes and Measures This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care–sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Results Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity–acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (−0.2 percentage points; 95% CI, −1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, −1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, −0.4 to 1.3 percentage points; P = .30). Conclusions and Relevance This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs.
Collapse
Affiliation(s)
- Robert Tyler Braun
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Hye-Young Jung
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Lawrence P. Casalino
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Zachary Myslinski
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Mark Aaron Unruh
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| |
Collapse
|
3
|
Shibasaki K, Asahi T, Kuribayashi M, Tajima Y, Marubayashi M, Iwama R, Akishita M, Ogawa S. Potential prescribing omissions of anti-osteoporosis drugs is associated with rehabilitation outcomes after fragility fracture: Retrospective cohort study. Geriatr Gerontol Int 2021; 21:386-391. [PMID: 33641245 DOI: 10.1111/ggi.14145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/11/2021] [Accepted: 02/14/2021] [Indexed: 12/18/2022]
Abstract
AIM We investigated the association between rehabilitation outcomes and polypharmacy, potentially inappropriate medications and potential prescribing omissions in older adults with fragility fractures. METHODS In total, we registered 217 older adults with fragility fractures (hip or vertebral) retrospectively and examined the association between rehabilitation outcome and polypharmacy, potentially inappropriate medications and potential prescribing omissions. Polypharmacy was defined as five or more drugs. Potentially inappropriate medications and potential prescribing omissions were defined by the Beers criteria (2015) and the screening tool to alert to treatment criteria version 2, respectively. The outcome was functional independence measure gain (functional independence measure at discharge - functional independence measure at admission). RESULTS Multiple regression analyses revealed no association between functional independence measure gain and polypharmacy (crude: β = 0.058, P = 0.858; adjusted model: β = 0.013, P = 0.869) or potentially inappropriate medications (crude: β = 0.100, P = 0.144; adjusted model: β = 0.084, P = 0.260). However, there was a significant association between functional independence measure gain and potential prescribing omissions (crude: β = 0.167, P = 0.014; adjusted model: β = 0.180, P = 0.016). Participants without potential prescribing omissions (in other words, participants who were prescribed anti-osteoporosis drugs) had a greater functional independence measure gain than participants with potential prescribing omissions (in other words, those that were not prescribed anti-osteoporosis drugs). CONCLUSION To the best of our knowledge, this study is the first to report that participants without potential prescribing omissions had significantly improved rehabilitation outcomes. Geriatr Gerontol Int 2021; 21: 386-391.
Collapse
Affiliation(s)
- Koji Shibasaki
- Department of Rehabilitation Medicine, Asahi Neurology and Rehabilitation Hospital, Matsudo City, Japan.,Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiomi Asahi
- Department of Rehabilitation Medicine, Asahi Neurology and Rehabilitation Hospital, Matsudo City, Japan
| | - Mari Kuribayashi
- Department of Rehabilitation Medicine, Asahi Neurology and Rehabilitation Hospital, Matsudo City, Japan
| | - Yuriko Tajima
- Department of Rehabilitation Medicine, Asahi Neurology and Rehabilitation Hospital, Matsudo City, Japan
| | - Miki Marubayashi
- Department of Rehabilitation Medicine, Asahi Neurology and Rehabilitation Hospital, Matsudo City, Japan
| | - Risa Iwama
- Department of Rehabilitation Medicine, Asahi Neurology and Rehabilitation Hospital, Matsudo City, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sumito Ogawa
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
4
|
Hershkovitz A, Nissan R. The Association Between Antipsychotic Drug Use and Rehabilitation Outcome in Post-Acute Hip Fractured Patients: A Retrospective Cohort Study. J Appl Gerontol 2020; 40:661-669. [DOI: 10.1177/0733464820904564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Antipsychotic (AP) use may lead to numerous side effects which may affect rehabilitation outcomes. A retrospective cohort study was carried out on 448 hip fractured patients admitted to a post-acute geriatric rehabilitation center. Functional improvement was measured by the Functional Independence Measure (FIM), motor FIM (mFIM), and mFIM effectiveness. A multiple linear regression model and regression analysis was used to evaluate the level of association between AP use and achievement of favorable functional gain. AP users exhibited lower functional ability on admission and at discharge, achieved a significantly lower functional gain and required longer rehabilitation time compared with nonusers. AP use by post-acute hip fractured patients negatively affects their chances of achieving favorable rehabilitation outcome after adjustment for confounders.
Collapse
Affiliation(s)
- Avital Hershkovitz
- “Beit Rivka” Geriatric Rehabilitation Center, Petah Tikva, Israel
- Tel Aviv University, Israel
| | - Ran Nissan
- “Beit Rivka” Geriatric Rehabilitation Center, Petah Tikva, Israel
| |
Collapse
|
5
|
Functional recovery in hip fracture patients: the role of pharmacotherapy. Aging Clin Exp Res 2020; 32:49-57. [PMID: 30900212 DOI: 10.1007/s40520-019-01175-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 03/11/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM The aim of this prospective observational cohort study was to verify the relationship between number of drugs used and functional outcome in hip fracture patients undergoing rehabilitation. METHODS This study was conducted on 139 patients with hip fracture who underwent a rehabilitation program. Efficiency rate in the Functional Independence Measure (FIM) and Berg Balance Scale (BBS), and length of stay (LOS) were the outcome measures. RESULTS At the end of rehabilitation, 66.1% of patients showed an increase in number of drugs used, while 33.9% used the same or lower number of drugs than at admission. At the end of rehabilitation patients with increased pharmacotherapy took a higher total number of drug classes (p = 0.001), had longer LOS (p = 0.009) and lower Berg efficiency (p = 0.048) than patients with the same or lower pharmacotherapy. The number of drugs used at discharge was an independent determinant of LOS (beta = 0.19, p = 0.022) and FIM efficiency (beta = - 0.20, p = 0.025). Age was a determinant of LOS (beta = 0.17, p = 0.044) and BBS efficiency (beta = - 0.23, p = 0.009), while CIRS severity was a determinant of BBS efficiency only (beta = - 0.22, p = 0.016). DISCUSSION Findings of study indicate that in hip fracture patients, the number of drugs prescribed at discharge is an important indicator of LOS and rehabilitation efficiency. CONCLUSIONS These findings can help the physician to better plan the rehabilitation of hip fracture patients who require polypharmacy.
Collapse
|
6
|
Randle JM, Heckman G, Oremus M, Ho J. Intermittent antipsychotic medication and mortality in institutionalized older adults: A scoping review. Int J Geriatr Psychiatry 2019; 34:906-920. [PMID: 30907448 DOI: 10.1002/gps.5106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 03/17/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE/BACKGROUND Antipsychotic use appears to increase mortality risk among older adults with dementia. Whether this risk is similar for regular or intermittent use is unknown. This scoping review aims to explore the temporal association between antipsychotic use and mortality risk for older institutionalized adults. METHOD We conducted a scoping review using Medline (PubMed), EMBASE, CINAHL, and the Cochrane libraries between October 2018 and January 2019. RESULTS Twenty-eight articles met review criteria. We found that different antipsychotic medications present different safety profiles. The risk of mortality was highest with conventional antipsychotic use and within 40 days of antipsychotic initiation. CONCLUSIONS Conventional antipsychotic use increases mortality for older institutionalized adults. The evidence for atypical antipsychotics is less clear. Mortality risk appears highest within 30 to 40 days of initiating antipsychotic treatment. This temporal association suggests increased mortality may actually be the result of some previously unrecognized illness, comorbidity, change in health status, or increased frailty, rather than an idiosyncrasy of the antipsychotic itself.
Collapse
Affiliation(s)
- Jason M Randle
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - George Heckman
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.,Schlegel Research Institute for Aging, Waterloo, Ontario, Canada
| | - Mark Oremus
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Joanne Ho
- Schlegel Research Institute for Aging, Waterloo, Ontario, Canada.,Department of Medicine, McMaster University, Kitchener, Ontario, Canada
| |
Collapse
|
7
|
Nadash P, Hefele JG, Miller EA, Barooah A, Wang X(J. A National-Level Analysis of the Relationship Between Nursing Home Satisfaction and Quality. Res Aging 2018; 41:215-240. [DOI: 10.1177/0164027518805001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Little research has explored the relationship between consumer satisfaction and quality in nursing homes (NHs) beyond the few states mandating satisfaction surveys. We examine this relationship through data from 1,765 NHs in the 50 states and District of Columbia using My InnerView resident or family satisfaction instruments in 2013 and 2014, merged with Certification and Survey Provider Enhanced Reporting, LTCfocus, and NH Compare (NHC) data. Family and resident satisfaction correlated modestly; both correlated weakly and negatively with any quality-of-care (QoC) and any quality-of-life deficiencies and positively with NHC five-star ratings; this latter positive association persisted after covariate adjustment; the negative relationship between QoC deficiencies and family satisfaction also remained. Overall, models explained relatively small proportions of satisfaction variance; correlates of satisfaction varied between residents and families. Findings suggest that satisfaction is a unique dimension of quality and that resident and family satisfaction represent different constructs.
Collapse
Affiliation(s)
- Pamela Nadash
- Department of Gerontology, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston, Boston, MA, USA
| | - Jennifer Gaudet Hefele
- Department of Gerontology, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston, Boston, MA, USA
| | - Edward Alan Miller
- Department of Gerontology, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston, Boston, MA, USA
| | - Adrita Barooah
- Department of Gerontology, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston, Boston, MA, USA
| | - Xiao (Joyce) Wang
- Department of Gerontology, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston, Boston, MA, USA
| |
Collapse
|
8
|
Wang KN, Bell JS, Chen EYH, Gilmartin-Thomas JFM, Ilomäki J. Medications and Prescribing Patterns as Factors Associated with Hospitalizations from Long-Term Care Facilities: A Systematic Review. Drugs Aging 2018; 35:423-457. [PMID: 29582403 DOI: 10.1007/s40266-018-0537-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Residents of long-term care facilities (LTCFs) are at high risk of hospitalization. Medications are a potentially modifiable risk factor for hospitalizations. OBJECTIVE Our objective was to systematically review the association between medications or prescribing patterns and hospitalizations from LTCFs. METHODS We searched MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and International Pharmaceutical Abstracts (IPA) from inception to August 2017 for longitudinal studies reporting associations between medications or prescribing patterns and hospitalizations. Two independent investigators completed the study selection, data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Tools. RESULTS Three randomized controlled trials (RCTs), 22 cohort studies, five case-control studies, one case-time-control study and one case-crossover study, investigating 13 different medication classes and two prescribing patterns were included. An RCT demonstrated that high-dose influenza vaccination reduced all-cause hospitalization compared with standard-dose vaccination (risk ratio [RR] 0.93; 95% confidence interval [CI] 0.88-0.98). Another RCT found no difference in hospitalization rates between oseltamivir as influenza treatment and oseltamivir as treatment plus prophylaxis (treatment = 4.7%, treatment and prophylaxis = 3.5%; p = 0.7). The third RCT found no difference between multivitamin/mineral supplementation and hospitalization (odds ratio [OR] 0.94; 95% CI 0.74-1.20) or emergency department visits (OR 1.05; 95% CI 0.76-1.47). Two cohort studies demonstrated influenza vaccination reduced hospitalization. Four studies suggested polypharmacy and potentially inappropriate medications (PIMs) increased all-cause hospitalization. However, associations between polypharmacy (two studies), PIMs (one study) and fall-related hospitalizations were inconsistent. Inconsistent associations were found between psychotropic medications with all-cause and cause-specific hospitalizations (11 studies). Warfarin, nonsteroidal anti-inflammatory drugs, pantoprazole and vinpocetine but not long-term acetylsalicylic acid (aspirin), statins, trimetazidine, digoxin or β-blockers were associated with all-cause or cause-specific hospitalizations in single studies of specific resident populations. Most cohort studies assessed prevalent rather than incident medication exposure, and no studies considered time-varying medication use. CONCLUSION High-quality evidence suggests influenza vaccination reduces hospitalization. Polypharmacy and PIMs are consistently associated with increased all-cause hospitalization.
Collapse
Affiliation(s)
- Kate N Wang
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Parkville Campus, 381 Royal Parade, Parkville, VIC, 3052, Australia.
| | - J Simon Bell
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Parkville Campus, 381 Royal Parade, Parkville, VIC, 3052, Australia.,NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, NSW, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Esa Y H Chen
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Parkville Campus, 381 Royal Parade, Parkville, VIC, 3052, Australia.,NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, NSW, Australia
| | - Julia F M Gilmartin-Thomas
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Jenni Ilomäki
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Parkville Campus, 381 Royal Parade, Parkville, VIC, 3052, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
9
|
Berry SD, Rothbaum RR, Kiel DP, Lee Y, Mitchell SL. Association of Clinical Outcomes With Surgical Repair of Hip Fracture vs Nonsurgical Management in Nursing Home Residents With Advanced Dementia. JAMA Intern Med 2018; 178:774-780. [PMID: 29801122 PMCID: PMC5997966 DOI: 10.1001/jamainternmed.2018.0743] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE The decision whether to surgically repair a hip fracture in nursing home (NH) residents with advanced dementia can be challenging. OBJECTIVE To compare outcomes, including survival, among NH residents with advanced dementia and hip fracture according to whether they underwent surgical hip fracture repair. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective cohort study of 3083 NH residents with advanced dementia and hip fracture, but not enrolled in hospice care, using nationwide Medicare claims data linked with Minimum Data Set (MDS) assessments from January 1, 2008, through December 31, 2013. METHODS Residents with advanced dementia were identified using the MDS. Medicare claims were used to identify hip fracture and to determine whether the fracture was managed surgically. Survival between surgical and nonsurgical residents was compared using multivariable Cox proportional hazards with inverse probability of treatment weighting (IPTW). All analyses took place between November 2015 and January 2018. Among 6-month survivors, documented pain, antipsychotic drug use, physical restraint use, pressure ulcers, and ambulatory status were compared between surgical and nonsurgical groups. RESULTS Among 3083 residents with advanced dementia and hip fracture (mean age, 84.2 years; 79.2% female [n = 2441], 28.5% ambulatory [n = 879]), 2615 (84.8%) underwent surgical repair. By 6-month follow-up, 31.5% (n = 824) and 53.8% (n = 252) of surgically and nonsurgically managed residents died, respectively. After IPTW modeling, surgically managed residents were less likely to die than residents without surgery (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.79-0.98). Among 2007 residents who survived 6 months, residents with surgical vs nonsurgical management had less docmented pain (29.0% [n = 465] vs 30.9% [n = 59]) and fewer pressure ulcers (11.2% [n = 200] vs 19.0% [n = 41]). In IPTW models, surgically managed residents reported less pain (aHR, 0.78; 95% CI, 0.61-0.99) and pressure ulcers (aHR, 0.64; 95% CI, 0.47-0.86). There was no difference between antipsychotic drug use and physical restraint use between the groups. Few survivors remained ambulatory (10.7% [n = 55] of surgically managed vs 4.8% [n = 1] without surgery). CONCLUSIONS AND RELEVANCE Surgical repair of a hip fracture was associated with lower mortality among NH residents with advanced dementia and should be considered together with the residents' goals of care in management decisions. Pain and other adverse outcomes were common regardless of surgical management, suggesting the need for broad improvements in the quality of care provided to NH residents with advanced dementia and hip fracture.
Collapse
Affiliation(s)
- Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts
| | - Randi R Rothbaum
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Division of Geriatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Douglas P Kiel
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice & Center for Gerontology, Brown University School of Public Health, Providence, Rhode Island
| | - Susan L Mitchell
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts
| |
Collapse
|
10
|
Pitzul KB, Munce SEP, Perrier L, Beaupre L, Morin SN, McGlasson R, Jaglal SB. Scoping review of potential quality indicators for hip fracture patient care. BMJ Open 2017; 7:e014769. [PMID: 28325859 PMCID: PMC5372037 DOI: 10.1136/bmjopen-2016-014769] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/17/2017] [Accepted: 02/21/2017] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The purpose of this study is to identify existing or potential quality of care indicators (ie, current indicators as well as process and outcome measures) in the acute or postacute period, or across the continuum of care for older adults with hip fracture. DESIGN Scoping review. SETTING All care settings. SEARCH STRATEGY English peer-reviewed studies published from January 2000 to January 2016 were included. Literature search strategies were developed, and the search was peer-reviewed. Two reviewers independently piloted all forms, and all articles were screened in duplicate. RESULTS The search yielded 2729 unique articles, of which 302 articles were included (11.1%). When indicators (eg, in-hospital mortality, acute care length of stay) and potential indicators (eg, comorbidities developed in hospital, walking ability) were grouped by the outcome or process construct they were trying to measure, the most common constructs were measures of mortality (outcome), length of stay (process) and time-sensitive measures (process). There was heterogeneity in definitions within constructs between studies. There was also a paucity of indicators and potential indicators in the postacute period. CONCLUSIONS To improve quality of care for patients with hip fracture and create a more efficient healthcare system, mechanisms for the measurement of quality of care across the entire continuum, not just during the acute period, are required. Future research should focus on decreasing the heterogeneity in definitions of quality indicators and the development and implementation of quality indicators for the postacute period.
Collapse
Affiliation(s)
- Kristen B Pitzul
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sarah E P Munce
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Laure Perrier
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Beaupre
- Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | | | - Susan B Jaglal
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
11
|
Forsberg MM. Delirium Update for Postacute Care and Long-Term Care Settings: A Narrative Review. J Osteopath Med 2017; 117:32-38. [DOI: 10.7556/jaoa.2017.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Advances have been made in our understanding of the neuropathogenesis, recognition, and strategies for reducing the incidence of delirium in acute-care settings. However, relatively little attention has been given to delirium in elderly patients in the postacute care (PAC) and long-term care (LTC) settings. The present article reviews the most relevant current research pertaining to this population. Hospital patients with delirium are often discharged to PAC settings. Delirium that develops in the LTC setting is often more insidious and subtle in presentation. Despite incorporating systematic screening tools for delirium in PAC and LTC settings, delirium prevention strategies have not yet been shown to be beneficial beyond the acute-care setting. The management of delirium combined with dementia and guidance on when it is appropriate to use antipsychotic medications is also discussed.
Collapse
|
12
|
Castle N, Engberg JB, Wagner LM, Handler S. Resident and Facility Factors Associated With the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set. J Appl Gerontol 2016; 36:173-194. [DOI: 10.1177/0733464815584666] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective: This research examined resident and facility-specific factors associated with a diagnosis of a urinary tract infection (UTI) in the nursing home setting. Method: Minimum Data Set and Online Survey, Certification and Reporting system data were used to identify all nursing home residents in the United States on April 1, 2006, who did not have a UTI ( n = 1,138,418). Residents were followed until they contracted a UTI (9.5%), died (8.3%), left the nursing home (33.2%), or the year ended (49.0%). A Cox proportional hazards model was estimated, controlling for resident and facility characteristics and for the state of residence. Result: The presence of an indwelling catheter was the primary predictor of whether a resident contracted a UTI (adjusted incidence ratio = 3.35, p < .001), but only 6.1% of the residents in the sample had such a catheter. Therefore, only one eighth of the UTIs were contracted by residents with a catheter. Thus, subsequent analysis examined the populations with and without catheters separately. Demographic characteristics (such as age) have a much greater association with incidence among residents without catheters. The association with facility factors such as percentage of Medicaid residents, for-profit, and chain status was less significant. Estimates regarding staffing levels indicate that increased contact hours with more highly educated nursing staff are associated with less catheter use. Discussion: Several facility-specific risk factors are of significance. Of significance, UTIs may be reduced by modifying factors such as staffing levels.
Collapse
|
13
|
Bakken MS, Schjøtt J, Engeland A, Engesaeter LB, Ruths S. Antipsychotic Drugs and Risk of Hip Fracture in People Aged 60 and Older in Norway. J Am Geriatr Soc 2016; 64:1203-9. [DOI: 10.1111/jgs.14162] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Marit S. Bakken
- Department of Global Public Health and Primary Care; Faculty of Medicine and Dentistry; University of Bergen; Bergen Norway
- Kavli Research Centre for Geriatrics and Dementia; Haraldsplass Deaconess Hospital; Bergen Norway
| | - Jan Schjøtt
- Department of Clinical Science; Faculty of Medicine and Dentistry; University of Bergen; Bergen Norway
- Section of Clinical Pharmacology; Laboratory of Clinical Biochemistry; Haukeland University Hospital; Bergen Norway
- Regional Medicines Information and Pharmacovigilance Centre; Haukeland University Hospital; Bergen Norway
| | - Anders Engeland
- Department of Global Public Health and Primary Care; Faculty of Medicine and Dentistry; University of Bergen; Bergen Norway
- Department of Pharmacoepidemiology; Norwegian Institute of Public Health; Oslo Norway
| | - Lars B. Engesaeter
- Department of Clinical Science; Faculty of Medicine and Dentistry; University of Bergen; Bergen Norway
- Norwegian Arthroplasty Registry; Department of Orthopaedics and Department of Clinical Medicine; Haukeland University Hospital; Bergen Norway
| | - Sabine Ruths
- Department of Global Public Health and Primary Care; Faculty of Medicine and Dentistry; University of Bergen; Bergen Norway
- Research Unit for General Practice; Uni Research Health; Bergen Norway
| |
Collapse
|
14
|
Does More Therapy in Skilled Nursing Facilities Lead to Better Outcomes in Patients With Hip Fracture? Phys Ther 2016; 96:81-9. [PMID: 26586858 PMCID: PMC4706596 DOI: 10.2522/ptj.20150090] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 11/05/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Skilled nursing facilities (SNFs) have increasingly been providing more therapy hours to beneficiaries of Medicare. It is not known whether these increases have improved patient outcomes. OBJECTIVE The study objectives were: (1) to examine temporal trends in therapy hour volumes and (2) to evaluate whether more therapy hours are associated with improved patient outcomes. DESIGN This was a retrospective cohort study. METHODS Data sources included the Minimum Data Set, Medicare inpatient claims, and the Online Survey, Certification, and Reporting System. The study population consisted of 481,908 beneficiaries of Medicare fee-for-service who were admitted to 15,496 SNFs after hip fracture from 2000 to 2009. Linear regression models with facility and time fixed effects were used to estimate the association between the quantity of therapy provided in SNFs and the likelihood of discharge to home. RESULTS The average number of therapy hours increased by 52% during the study period, with relatively little change in case mix at SNF admission. An additional hour of therapy per week was associated with a 3.1-percentage-point (95% confidence interval=3.0, 3.1) increase in the likelihood of discharge to home. The effect of additional therapy decreased as the Resource Utilization Group category increased, and additional therapy did not benefit patients in the highest Resource Utilization Group category. LIMITATIONS Minimum Data Set assessments did not cover details of therapeutic interventions throughout the entire SNF stay and captured only a 7-day retrospective period for measures of the quantity of therapy provided. CONCLUSIONS Increases in the quantity of therapy during the study period cannot be explained by changes in case mix at SNF admission. More therapy hours in SNFs appear to improve outcomes, except for patients with the greatest need.
Collapse
|
15
|
Mattingly TJ. A Review Exploring the Relationship Between Nursing Home Staffing and Antipsychotic Medication Use. Neurol Ther 2015; 4:169-75. [PMID: 26662363 PMCID: PMC4685870 DOI: 10.1007/s40120-015-0032-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Indexed: 12/02/2022] Open
Abstract
Staffing level requirements for nursing homes exist at state and federal levels in the United States. While quality of care measures may include antipsychotic (AP) prescribing, the appropriate use of APs as chemical restraints in nursing homes continues to be debated. Although the two variables appear to be related, improved research methods and availability of accurate staffing data will be needed to understand causal relationships regarding AP use for facility dwelling patients.
Collapse
Affiliation(s)
- T Joseph Mattingly
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.
| |
Collapse
|